Artur Wichniarek

Numerous medical studies have examined the effects of male circumcision with mixed opinions regarding the benefits and risks of the procedure.

Positions of major health organizations

United States

The American Academy of Pediatrics (1999) found both potential benefits and risks in infant circumcision, however, there was insufficient data to recommend routine neonatal circumcision. In situations involving potential benefits and risks, and no immediate urgency, they state that "parents should determine what is in the best interest of the child". They continue, "To make an informed choice, parents of all male infants should be given accurate and unbiased information and be provided the opportunity to discuss this decision." They said it was legitimate to take medical, cultural, ethnic, traditional, and religious factors into account. If a decision to circumcise is made, the AAP recommend using analgesia to reduce pain, and also said that circumcision on newborns should be performed only if they are stable and healthy.

The American Medical Association (1999) noted that medical associations in the US, Australia, and Canada did not recommend routine circumcision of newborns. It supported the general principles of the 1999 Circumcision Policy Statement of the American Academy of Pediatrics

The American Academy of Family Physicians (January 2007) acknowledges the controversy surrounding circumcision and recommends that physicians discuss the potential harms and benefits of circumcision with all parents or legal guardians considering circumcision for newborn boys.

The American Urological Association (May 2007) states there are benefits and risks to circumcision. It feels that parents should consider medical benefits and risks, and ethnic, cultural, etc. factors when making this decision.

Canada

The Fetus and Newborn Committee of the Canadian Paediatric Society does not recommend routine circumcision for newborn boys. It posted "Circumcision: Information for Parents" in November 2004, and "Neonatal circumcision revisited" in 1996. The 1996 position statement says that "circumcision of newborns should not be routinely performed," (a statement with which the Royal Australasian College of Physicians concurs,) and the 2004 advice to parents says it "does not recommend circumcision for newborn boys. Many paediatricians no longer perform circumcisions."

United Kingdom

The British Medical Association's position (June 2006) was that male circumcision for medical purposes should only be used where less invasive procedures are either unavailable or not as effective. The BMA specifically refrained from issuing a policy regarding “non-therapeutic circumcision,” stating that as a general rule, it “believes that parents should be entitled to make choices about how best to promote their children’s interests, and it is for society to decide what limits should be imposed on parental choices.”

Australasia

The Royal Australasian College of Physicians states there is no medical indication for routine neonatal circumcision (emphasis as in the original). It states, "If the operation is to be performed, the medical attendant should ensure this is done by a competent operator, using appropriate anaesthesia and in a safe child-friendly environment"

Circumcision procedures

Circumcision removes the foreskin from the penis. For infant circumcision, clamps, such as the Gomco clamp, Plastibell, and Mogen are often used. Clamps cut the blood supply to the foreskin, stop any bleeding and protect the glans. Before using a clamp, the foreskin and the glans are separated with a blunt probe and/or curved hemostat.

• With the Plastibell, the foreskin and the clamp come away in three to seven days.

• With a Gomco clamp, a section of skin is first crushed with a hemostat then slit with scissors. The foreskin is drawn over the bell shaped portion of the clamp and inserted through a hole in the base of the clamp. The clamp is then tightened, "crushing the foreskin between the bell and the base plate." The crushing limits bleeding (provides hemostasis). While the flared bottom of the bell fits tightly against the hole of the base plate, the foreskin is then cut away with a scalpel from above the base plate. The bell prevents the glans being reached by the scalpel.

• With a Mogen clamp, the foreskin is grabbed dorsally with a straight hemostat, and lifted up. The Mogen clamp is then slid between the glans and hemostat, following the angle of the corona to "avoid removing excess skin ventrally and to obtain a superior cosmetic result," than with Gomco or Plastibell circumcisions. The clamp is locked shut, and a scalpel is used to cut the foreskin from the flat (upper) side of the clamp.

The frenulum may be cut if frenular chordee is evident.

Potential complications

Williams & Kapila state: "the literature abounds with reports of morbidity and even death as a result of circumcision." Complications may be immediate or delayed, and complications from bleeding, infection and poorly carried out circumcisions can be catastrophic. The immediate complications may be classified as surgical mishap, hemorrhage, infection and anesthetic risk.

The American Medical Association quotes a complication rate of 0.2%–0.6%, based on the studies of Gee and Harkavy. These same studies are quoted by the American Academy of Pediatrics. The American Academy of Family Physicians quotes a range of anywhere between 0.1% and 35%. The Canadian Paediatric Society cite these results in addition to other figures ranging anywhere between 0.06% to 55%, and remark that Williams & Kapila suggested that 2-10% is a realistic estimate. The RACP states that the penis is lost in 1 in 1,000,000 circumcisions.

Deaths have been reported. The American Academy of Family Physicians states that death is rare. It estimates a death rate from circumcision of 1 infant in 500,000. Gairdner's 1949 study reported that an average of 16 children per year out of about 90,000 died following circumcision in the UK. He found that most deaths had occurred suddenly under anaesthesia and could not be explained further, but hemorrhage and infection had also proven fatal. Deaths attributed to phimosis and circumcision were grouped together, and Gairdner argued that such deaths were probably due to the circumcision operation.

Adult circumcisions are often performed without clamps, and require 4 to 6 weeks of abstinence from masturbation or intercourse after the operation to allow the wound to heal.

Immediate Complications

According to the AMA, blood loss and infection are the most common complications. Bleeding is mostly minor; applying pressure will stop it. These complications are less likely with a skilled and experienced circumciser. Kaplan identified other complications, including urinary fistulas, chordee, cysts, lymphedema, ulceration of the glans, necrosis of all or part of the penis, hypospadias, epispadias, impotence and removal of too much tissue, sometimes causing secondary phimosis. He stated “Virtually all of these complications are preventable with only a modicum of care" and "most such complications occur at the hands of inexperienced operators who are neither urologists nor surgeons.”

• Infection

Infections are usually minor and local, but sometimes they have led to urinary tract infection, life-threatening systemic infections, meningitis or death.

Staphylococcal infections are a growing problem in hospitals for any operation, and MSSA (methicillin susceptible) strains of s.aureus have affected neonatal nurseries. Some research has found a statistically significant relationship between golden staph (Staphylococcus aureus) infections and whether an infant has been circumcised Boys have been found to be far more susceptible to golden staph infections than girls and methicillin susceptible strains (MSSA) have infected circumcision wounds. Enzenauer stated: "Circumcision, which is performed on approximately 90 per cent of male infants born in our hospital, may be a factor. Circumcision, by its very nature. requires more staff-patient "hands-on" contact, both during the procedure and during preoperative and postoperative care."

Images of an infant with a life threatening s.aureus infection may be found here

• Herpes

A minority of Jewish circumcisers practise Metzizah b'peh, (oral suction). Three published medical papers have suggested a link between metzitzah bipeh and neonatal herpes in two cases in New York, 8 cases in Israel and one in Canada, one of whom suffered brain damage. In New York, three additional cases of herpes by one mohel were allegedly linked with oral metzizah. One baby died and one suffered brain damage. In response to this, New York public health officials warned the Jewish community about the dangers of metzizah b'peh

The Israeli researchers said:

"We support ritual circumcision but without oral metzitzah, which might endanger the newborns and is not part of the religious procedure," write researcher Benjamin Gesundheit, MD, of Ben Gurion University in Israel, and colleagues

The New York City Department of Health and Mental Hygiene said:

Because there is no proven way to reduce the risk of herpes infection posed by metzitzah b'peh, the Health Department recommends that infants being circumcised not undergo metzitzah b'peh. (emphasis in the original)

However, in May 2006, After the NYC Dept of Health refused to do DNA testing to conclusively determine the source of infection, the ultra orthodox rabbinate, not the Department of Health for New York State, pushed for the passage of the NYS protocol for the performance of metzitzah b'peh. requiring DNA testing of at least four persons including the parents, if a baby were to get herpes following ritual circumcision that included oral suctioning of the wound. It is interesting to note despite the fact that metzitzah is performed exclusively in all circumcisions in chasidic strongholds such as Williamsburg, Monroe, New Square, and Crown Heights, there has never been a case of neonatal herpes reported. Furthermore despite the predictions of thousands of sick and dying babies, since the passage of the NYS protocol requiring DNA testing there has not been a single case reported.

Dr. Antonia C. Novello, Commissioner of Health for New York State, together with a board of rabbis and doctors, worked to allow the practice of metzizah b'peh to continue while still meeting the Department of Health's responsibility to protect the public health.

Dr. Novello said:

“I want to reiterate that the welfare of the children of your community is our common goal and that it is not our intent to prohibit metzizah b'peh after circumcision, rather our intent is to suggest measures that would reduce the risk of harm, if there is any, for future circumcisions where metzizah b'peh is the customary procedure and the possibility of an infected mohel may not be ruled out. I know that successful solutions can and will be based on our mutual trust and cooperation.”

• Hemorrhage

Bleeding after circumcision is usually minor and easily controlled, but on rare occasions it has led to shock from blood loss (hypovolemic shock) or death (exsanguination).

Coagulation disorders affect from 2 to 4 per cent of the population and the condition is underdiagnosed/ Severe bleeding following circumcision may be a sign of hemophilia.

• Surgical mishap

Mistakes can happen with any surgery. Surgical mistakes from circumcision include documented cases of penile denudation, cutting off part or all of the glans penis, urethral fistula, several types of injury associated with certain types of circumcision clamps used and penile necrosis which results in loss of the entire penis.

• Anesthetic risk

Anesthetic risk includes methaemglobinaemia.

Delayed Complications

• Meatal stenosis may be a common longer-term complication from circumcision. Recent publications give a frequency of occurrence between 0.9% and 9% to 10%. The opening to the urethra (meatus) may also be affected, leading to inflammation and meatal ulceration.
• Urinary retention [3];
• Venous stasis, the slowing down of venous blood flow [4] [5]
• Concealed penis [6][7];
• Adhesions [8];
• Skin bridges [9], when the cut skin attaches to the glans penis. Skin bridges do not commonly require surgical correction; rather, a brief, simple office procedure may be performed.
• Painful erections. [10]

Psychological and emotional consequences

Moses et al. (1998) state that "scientific evidence is lacking" for psychological and emotional harm, and cite a longitudinal study which did not find any difference in developmental and behavioural indices. Goldman (1999) discussed the possible trauma of circumcision on children and parents, anxieties over the circumcised state, a tendency to repeat the trauma, and suggested a need on the part of circumcised doctors to find medical justifications for the procedure. Some organizations have formed support groups for men who are resentful about being circumcised.

The American Academy of Pediatrics' policy states:

Some common painful minor procedures, such as circumcision, do not always receive the warranted attention to comfort issues. Available research indicates that newborn circumcisions are a significant source of pain during the procedure and are associated with irritability and feeding disturbances during the days afterward. Opportunities for alleviating pain exist before, during, and after the procedure, and many interventions are effective.[11]

-- The Assessment and Management of Acute Pain in Infants, Children and Adolescents, 2001.

Many studies have examined adverse effects of the procedure; some employing various forms of pain relief. A few of these findings are summarised in the following table.

Study1	Effects noted	Unstated
Marshall (1982) [12]	Brief and transitory effects on mother-infant interactions observed during hospital feeding sessions.
No pain relief
Howard (1994) [13]	Significant increases in heart rate, respiratory rate, and crying. Deteriorated feeding behaviour.
Taddio (1997) [14]	Stronger pain response during vaccination 4 to 6 months later.
Lander (1997) [15] [16]	Sustained elevation of heart rate and high-pitched cry. Choking and apnea in 2 of 11 infants circumcised without pain relief.
Acetaminophen (Tylenol/Paracetamol)
Howard (1994) [17]	Significant increases in heart rate, respiratory rate, and crying. Deteriorated feeding behaviour. Improved comfort after postoperative period.
Taddio (1997) [18]	Stronger pain response during vaccination 4 to 6 months later, though attenuated as compared to placebo.
EMLA (topical anaesthetic)
Lander (1997) [19]	Significantly less crying and lower heart rates compared with those circumcised without anaesthetic (see above).
Dorsal penile nerve block (DPNB)
Kirya (1978) [20]	Circumcision pain eliminated except when the injection needle was misplaced.
Lander (1997) [21]	Significantly less crying and lower heart rates than circumcision without anaesthetic. Not effective during foreskin separation and incision.
Ring block
Lander (1997) [22]	Significantly less crying and lower heart rates than circumcision without anaesthetic. Equally effective through all stages of the circumcision

¹ Studies investigating several forms of pain relief have one entry for each form.

Howard et al report that neonatal circumcision without anaesthesia and using acetaminophen (Tylenol) results in deteriorated breast-feeding immediately after circumcision.[23] They commented:

Numerous studies have shown that circumcision causes severe pain. This is shown by measures of crying, heart rate, respiratory rate, transcutaneous PO₂, and cortisol levels…[]… Neonatal circumcision are often performed on the day of discharge with many neonates leaving the hospital 3 to 6 hours postoperatively. Thus the observed deterioration in ability to breast-feed may potentially contribute to breast-feeding failure. Furthermore some neonates in this study required formula supplementation because of maternal frustration with attempts at breast-feeding, or because the neonate was judged unable to breast-feed postoperatively. This finding is disconcerting because early formula supplementation is associated with decreased breast-feeding duration.

Howard et al. concluded that:

Acetaminophen was not found to ameliorate either the intra-operative or the immediate postoperative pain of circumcision, although it seems that it may provide some benefit after the postoperative period.[24]

Many other studies have investigated the pain caused by circumcision, and the effectiveness of different forms of analgesia and anaesthesia.

Taddio et al reported behavioural changes (heightened pain responses) during vaccinations in children circumcised with EMLA cream and with no anaethesia at the 99.9+% statistical confidence level (p<0.001) four to six months after their circumcision, suggesting a persistent effect on pain response. [25] The researchers commented:

"Study of the vaccination pain response of infants who had received more effective circumcision pain management (i.e., dorsal penile nerve block and adequate postoperative pain management) would be interesting."

Kirya and Werthmann investigated the effect of dorsal penile nerve block (DPNB), describing it as "painless".[26] However, Lander et al found that DPNB is less effective than ring block.[27]

Marshall et al report that the stress of neonatal circumcision may alter feeding behaviour and some male infants may be unable to breastfeed after circumcision.[28] They commented:

Despite differences between control and experimental infants shortly after surgery, by 24 h post-operatively no significant differences were observed between the groups. The behavioral effects of circumcision in the present study were immediate but brief. This should be comforting information to those who provide care for newborns and for their parents.[29]

Marshall et al did not report whether anaesthesia was used. Fergusson et al. found no evidence in their study of an association between neonatal circumcision and breastfeeding. They concluded that "the findings do not support the view that neonatal circumcision disrupts breastfeeding."

Potential benefits

Conditions affecting the prostate

Ravich and Ravich reported that in patients operated on for prostatic obstruction, 1.8% of obstructions in Jews were cancerous, compared with 19% in non-Jews. Ross et al. reported on two case-control studies in Southern California. Both studies included 142 cases and in each study the risk was lower in circumcised men (relative risk of 0.5 in whites and 0.6 in blacks). Mandel and Schuman reported on a case-control study with 250 cases. Compared with controls drawn from their neighborhood, circumcised men were less likely to develop prostate cancer (odds ratio 0.82). Ewings and Bowie performed a case-control study of 159 cases of prostate cancer, and found that circumcised men were at a reduced risk (odds ratio 0.62). The authors noted: "...some statistically significant associations were found, although these can only be viewed as hypothesis generating in this context."

McCredie et al (2001) studied 1,216 men aged 40-69 years using the International Prostate Symptom Score, and found that being circumcised was associated with a higher prevalence of moderate-to-severe urinary symptoms.

Human Papilloma Virus (HPV)

A meta-analysis by Van Howe in 2006 found that there was no significant association between circumcision status and HPV infection and that "the medical literature does not support the claim that circumcision reduces the risk for genital HPV infection". However, Castellsagué et al. maintain that this meta-analysis was flawed, and further note that a re-analysis of the same data "... clearly shows, no matter how the studies are grouped, a moderate to strong protective effect of circumcision on penile HPV and related lesions."

In several studies, uncircumcised men were found to have a greater incidence of human papilloma virus (HPV) infection than circumcised men. One of these studies has been criticized on methodological grounds. One study found no statistically significant difference in the incidence of HPV infection between circumcised and uncircumcised men.

Two studies have shown that circumcised men report, or were found to have, a higher prevalence of genital warts than uncircumcised men.

The Medical College of Georgia is now studying the impact of the new vaccine against "HPV types 16 and 18, the two most common causes of cervical and penile cancer"

Circumcision has been associated with a lower incidence of Human Papilloma Virus infection in males in several studies. HPV infection is a known risk factor in the development of penile cancer. Other studies suggest that circumcision may reduce the risk of more invasive forms of penile cancer. "In weighing the risks and benefits of circumcision, doctors consider the fact that penile cancer is one of the least common forms of cancer in the United States" and "Ultimately, decisions about circumcision are highly personal and depend more on social and religious factors than on medical evidence". They state that it is important to concentrate on the main risk factors: poor hygiene, having unprotected sex with multiple partners, and cigarette smoking. They also state that the current consensus of most experts is that circumcision should not be recommended as a prevention strategy for penile cancer.

HPV and cervical cancer

Some medical researchers have found evidence of a link between a higher incidence of cervical cancer in female partners of uncircumcised men and a higher incidence of penile human papillomavirus (HPV) in uncircumcised men.

Stern and Neely (1962) observed no protective effect of male circumcision in female partners. Punyaratabandhu et al. (1982) reported a protective effect in Thai women. Kjaer et al. (1991) reported an apparently protective effect in Dutch women, that failed to achieve statistical significance. Agarwal et al. (1993) observed a significantly protective effect among Indian women.

The role of male circumcision in female infection with HPV remains controversial. As Castellsagué (2002) said, "…it would not make sense to promote circumcision as a way to control cervical cancer in the United States, where Pap smears usually detect it at a treatable stage."

Smegma and cancer

In 1947, Plaut and Kohn-Speyer found that horse smegma had a carcinogenic effect on laboratory mice of the Paris R 3 strain. Six tumours developed in 190 mice treated with whole smegma, and three developed in 88 mice treated with the nonsaponifiable fraction. No tumours developed in the control group of 150 mice, which were treated with cerumen. The authors concluded: "Provided our results can be duplicated and improved, this may be the first experimental production of cancer by external application of an external product of the animal body." In 1958, Heins et al. concluded that human smegma could produce cancer of the cervix in dba-1 strain mice, if this stimulus continued for 14 months or more. However, Reddy and Baruah (1963) were unable to reproduce this effect, and they concluded that the carcinogenic effect, if it existed, must be weak. Wynder (1964) was uncertain about the connection between male circumcision, smegma and cervical cancer. In 2006, Van Howe and Hodges described claims of harm in human smegma as a "myth" which has "evolved over time and with retelling."

Penile cancer

Main article: Penile cancer

Penile cancer is a rare form of cancer, mostly occurring in men over the age of 60. Annually, there is one case in 100,000 men in the United States. Penile cancer is very rare in North America and Europe; it accounts for about 0.2% of cancers in men and 0.1% of cancer deaths in men in the United States. However, penile cancer is much more common in some parts of Africa and South America, where it accounts for up to 10% of cancers in men. Frisch et al evaluated penile cancer rates in Denmark and found that Danish men (who are predominantly not circumcised) had an incidence of 0.9-1.0 per 100,000 in 1975.

Kochen and McCurdy performed a life table analysis on penile cancer rates, and estimated that penile cancer affected uncircumcised males at a rate of 1 in 600. However, Poland has criticised the assumptions used in their analysis.

Burkitt (1973) states that the geographical distribution of penile cancer is strongly influenced by circumcision status. However, he notes wide differences in penile cancer rates between African tribes who do not practice circumcision, and suggests that additional etiological factors may be responsible.

The Canadian Paediatric Society (1982) assert that there could be genetic or environmental factors that influence the incidence of carcinoma and that the association with circumcision could be coincidental.

Childhood circumcision has been associated with a reduced incidence of penile cancer in numerous studies. Boczko and Freed (1979) stated that since Wolbarst's 1932 review, "there have been only eight documented cases of penile carcinoma in an individual circumcised in infancy." They described the ninth reported case, concluding that "performing it in infancy continues to be the most effective prophylactic measure against penile carcinoma." The AMA remarked that in six case series published from 1932 and 1986, "all penile cancers occurred in uncircumcised individuals."

Maden et al (1993) reported that the risk of penile cancer was greater in men who were never circumcised (OR 3.2; 95% CI 1.8-5.7) and among those who were circumcised after the neonatal period (OR 3.0; 95% CI 1.4-6.6). An editorial by Holly and Palefsky complimented the study for noting other risk factors for penile cancer, and also for providing corroborating evidence as to the association between a lack of neonatal circumcision and the development of penile cancer. However, they criticised include the study for combining data from invasive and in situ cancers. They concluded that as Maden reported that 20% of the men with penile cancer were circumcised at birth, the recommendation of circumcision for medical indications remained somewhat controversial and the risks and benefits must be weighed. The American Academy of Pediatrics made similar criticism, also noting the possibly inaccurate use of self-report to determine circumcision status.

Schoen et al (2000) studied the association between neonatal circumcision and invasive penile cancer, reporting that the relative risk for uncircumcised men was 22 times that of circumcised men.

Tseng et al (2001) studied the association between neonatal circumcision and both invasive penile cancer and carcinoma in situ. The authors reported that neonatal circumcision was associated with reduced risk of invasive penile cancer (OR 0.41; 95% CI 0.13–1.1) but not carcinoma in situ. The association was reduced when only subjects with no history of phimosis were included, and the authors concluded that the protective effect of circumcision may be mediated in large part by phimosis.

Daling et al (2005) examined the association between circumcision during childhood and invasive penile cancer and carcinoma in situ. Absence of circumcision in childhood was associated with increased risk of invasive penile cancer (OR 2.3; 95% CI 1.3-4.1), but not carcinoma in situ. When men with phimosis were excluded, no significant increase in risk of invasive penile cancer was observed.

Fleiss and Hodges, together with Cold, Storms and Van Howe, suggest that the "myth" that neonatal circumcision renders the subject immune to penile cancer can be traced back to an opinion article in 1932 by the American circumcisionist Abraham L. Wolbarst as a scare tactic to increase the rate of neonatal circumcision.

Fleiss and Hodges state that epidemiological studies have failed to prove Wolbarst's assertion. Stanton, however, notes that Fleiss and Hodges cited only a single such study, 'that of Maden et al, and, curiously, omit its main conclusion--that "absence of neonatal circumcision and potential resulting complications are associated with penile cancer."'

Cadman et al.'s (1984) study, said that using routine infant circumcision to prevent penile cancer would not be cost-effective; the costs of circumcising everyone would be over a hundred times the savings achieved.

Positions of medical organisations

The American Academy of Pediatrics (1999) stated that studies suggest that neonatal circumcision confers some protection from penile cancer, but circumcision at a later age does not seem to confer the same level of protection. Further, penile cancer is a rare disease and the risk of penile cancer developing in an uncircumcised man, although increased compared with a circumcised man, remains low. Similarly, the American Medical Association states that although neonatal circumcision seems to lower the risk of contracting penile cancer, because it is rare and occurs later in life, the use of circumcision as a preventive practice is not justified.

The Royal Australasian College of Physicians stated that the use of infant circumcision to prevent penile cancer alone in adulthood is not justified.

The American Cancer Society stated::

In the past, circumcision has been suggested as a way to prevent penile cancer. This suggestion was based on studies that reported much lower penile cancer rates among circumcised men than among uncircumcised men. However, most researchers now believe those studies were flawed because they failed to consider other factors that are now known to affect penile cancer risk.

Elsewhere, the ACS stated:

Circumcision seems to protect against penile cancer when it is done shortly after birth. Men who were circumcised as babies have less than half the chance of getting penile cancer than those who were not. The reasons for this are not entirely clear, but may be related to other known risk factors. For example, men who are circumcised cannot develop a condition called phimosis. Men with phimosis have an increased risk of penile cancer (see below). Also, circumcised men seem to be less likely to be infected with HPV, even after adjusting for differences in sexual behavior.

In weighing the risks and benefits of circumcision, doctors consider the fact that penile cancer is one of the least common forms of cancer in the United States. Neither the American Academy of Pediatrics nor the Canadian Academy of Pediatrics recommends routine circumcision of newborns (for medical reasons). In the end, decisions about circumcision are highly personal and depend more on social and religious factors than on medical evidence.

HIV/AIDS

According to Alcena, it was he who first hypothesised that low rates of circumcision in Africa were partly responsible for the continent's high rate of HIV infection. He did this via a letter to the New York State Journal of Medicine in August 1986. He also alleges that the late Aaron J. Fink stole his idea when Fink published a letter to the New England Journal of Medicine entitled A possible explanation for heterosexual male infection with AIDS, in October 1986.

In 1989 Cameron found uncircumcised men 8.2 times more likely to have HIV. Since then over 40 epidemiological studies have been conducted to investigate the relationship between circumcision and HIV infection.

At the 14th International AIDS conference in 2002, Changedia and Gilada reported that "Though circumcision offers protection in acquisition of HIV infection, our findings reveal that it does not reduce transmission of HIV in conjugal settings." Hunter et al. (1994), however, report that "Women whose husband or usual sex partner was uncircumcised had a threefold increase in risk of HIV, and this risk was present in almost all strata of potential confounding factors." Fonck et al. (2000) reported that "Partners of circumcised men had less-prevalent HIV infection."

Bonner (2000) reserved caution over using cirucmcision to prevent HIV: "Until we know why and how circumcision is protective, exactly what the relationship is between circumcision status and other STIs, and whether the effect seen in high-risk populations is generalisable to other groups, the wisest course is to recommend risk reduction strategies of proven efficacy, such as condom use."

The USAID document summarised research as of September 2002. It states:

A systematic review and meta-analysis of 28 published studies by the London School of Hygiene and Tropical Medicine, published in the journal AIDS in 2000, found that circumcised men are less than half as likely to be infected by HIV as uncircumcised men. A subanalysis of 10 African studies found a 71 percent reduction among higher-risk men. A September 2002 update considered the results of these 28 studies plus an additional 10 studies and, after controlling for various potentially confounding religious, cultural, behavioral, and other factors, had similarly robust findings. Recent laboratory studies in Chicago found HIV uptake in the inner foreskin tissue to be up to nine times more efficient than in a control sample of cervical tissue.

However, the Cochrane Library for Evidence-based Medicine's review of the data (2004) reported:

We found insufficient evidence to support an interventional effect of male circumcision on HIV acquisition in heterosexual men. The results from existing observational studies show a strong epidemiological association between male circumcision and prevention of HIV, especially among high-risk groups. However, observational studies are inherently limited by confounding which is unlikely to be fully adjusted for. In the light of forthcoming results from RCTs, the value of IPD analysis of the included studies is doubtful. The results of these trials will need to be carefully considered before circumcision is implemented as a public health intervention for prevention of sexually transmitted HIV.[30]

Nevertheless, the positive results of observational studies suggested that circumcision was "worth evaluating in randomised controlled trials.” (See the "Recent results" section below for results of these trials.)

At the 15th International AIDS Conference in 2004, Connolly et al. presented his report detailing the effects of circumcision in South Africa. They reported that, among racial groups, "circumcised Blacks showed similar rates of HIV as uncircumcised Blacks, (OR: 0.8, p = 0.4) however other racial groups showed a strong protective effect, (OR: 0.3, p = 0.01)." They added "When the data are further stratified by age of circumcision, there is a slight protective effect between early circumcision and HIV among Blacks, OR: 0.7, p = 0.4." They conclude that "in general, circumcision offers slight protection." At the same conference, Thomas et al. (2004) reported that "male circumcision is not associated with HIV or STI prevention in a U.S. Navy population."

Other researchers have contested the findings which indicate that circumcision reduces HIV transmission. For example, Van Howe produced a meta-analysis which found circumcised men at a greater risk for HIV infection. He further speculated that circumcision may be responsible for the increased number of partners, and therefore, the increased risk. Van Howe's work was reviewed by O'Farrell and Egger who said Van Howe used an inappropriate method for combining studies.

Weiss, Quigley and Hayes carried out a new meta-analysis on circumcision and HIV and found as follows: "Male circumcision is associated with a significantly reduced risk of HIV infection among men in sub-Saharan Africa, particularly those at high risk of HIV. These results suggest that consideration should be given to the acceptability and feasibility of providing safe services for male circumcision as an additional HIV prevention strategy in areas of Africa where men are not traditionally circumcised."

There are other studies of note. Kelly et al. investigated the age of male circumcision and risk of prevalent HIV infection in rural Uganda and found that circumcision before the age of 12 resulted in a reduction to 0.39 of the odds of being infected. The degree of protection varied with the age at which circumcision was performed. Those circumcised at between 13 and 20 years had an odds ratio of 0.46, and those circumcised after the age of 20 at an odds ratio of 0.78. They concluded: "Prepubertal circumcision is associated with reduced HIV risk, whereas circumcision after age 20 years is not significantly protective against HIV-1 infection."

Buvé and colleagues investigated the reasons why the HIV prevalence rate among pregnant women in many large towns in Central, East and southern Africa was higher (>30%) than in the cities and towns of most of West Africa (<10%). Between June 1997 and March 1998 surveys were carried out and blood samples were taken in 4 sites. Kisumu (Kenya) and Ndola (Zambia), in Central/East Africa, were selected as the towns with high HIV prevalence, while the low-prevalence towns in West Africa were Cotonou (Benin) and Yaoundé (Cameroon). "In conclusion, differences in the rate of HIV spread between the East African and West African cities studied cannot be explained away by differences in sexual behaviour alone. In fact, behavioural differences seem to be outweighed by differences in HIV transmission probability."

Bailey et al. (1999) interviewed 188 circumcised and 177 uncircumcised consenting Ugandan men in one of four native languages during April and May, 1997. Non-Muslim circumcised men were found to have a higher risk profile than uncircumcised men. Muslims generally had a lower risk profile than other circumcised men except they were less likely to have ever used a condom or to have used a condom during the last sex encounter. Bailey et al. concluded that "these results suggest that differences between circumcised and uncircumcised men in their sex practices and hygienic behaviors do not account for the higher risk of HIV infection found among uncircumcised men. Further consideration should be given to male circumcision as a prevention strategy in areas of high prevalence of HIV and other sexually transmitted diseases. Studies of the feasibility and acceptability of male circumcision in traditionally non-circumcising societies are warranted."

Kiwanuka et al.'s (1996) study on the relationship between religion and HIV in Rural Uganda was presented at the 1996 10th International AIDS Conference He said that: "Lower rates of HIV infection among Pentecostals appear to be associated with less alcohol consumption, sexual abstinence and fewer sexual partners, whereas the low HIV prevalence in Muslims appears to be associated with low reported alcohol consumption and male circumcision." Muslims, despite having the lowest rate of sexual abstinence and the highest rate of having two or more sexual partners, had the lowest level of HIV infection compared with the other religious groups in the study (Catholics, Protestants, and Pentecostals). The factor in common between the Muslims (14.5% seropositive) and the Pentecostals (14.6% seropositive) was the lower alcohol consumption rate in these two groups than amongst Protestants (19.2%) and Catholics (19.9%).

Studies have also been carried out as to the acceptability of male circumcision within traditionally non-circumcising communities. Kebaabetswe et al. found that "Male circumcision appears to be highly acceptable in Botswana. The option for safe circumcision should be made available to parents in Botswana for their male children. Circumcision might also be an acceptable option for adults and adolescents, if its efficacy as an HIV prevention strategy among sexually active people is supported by clinical trials."

Lagarde found that "More than 70% of the non-circumcised men (NCM) stated that they would want to be circumcised if MC were proved to protect against sexually transmitted diseases (STD)." Lagarde cautioned that "Our results strongly suggest that interventions including MC should carefully address the false sense of security that it may provide."

Bailey et al looked at the possible adverse effects of introducing male circumcision on a public health scale and the post operative satisfaction levels of 380 circumcisions on 18-24 year old consenting men. As to satisfaction; "At 30 days post-surgery, 99.3% of men reported being very satisfied and 0.7% somewhat satisfied with circumcision. None were dissatisfied." And with regard to adverse effects; "All were mild or moderate and resolved within hours or several days of detection." Their findings were presented at the 15th International AIDS Conference held in Bangkok in 2004.

In a recently published study in this regard , Reynolds et al found that male circumcision was strongly protective against HIV-1 infection with circumcised men being almost seven times less at risk of HIV infection than uncircumcised men. They further state that: "The specificity of this relation suggests a biological rather than behavioural explanation for the protective effect of male circumcision against HIV-1."

Baeten et al in a study published in The Journal of Infectious Diseases in 2005 found that uncircumcised men were at a greater than two-fold increased risk of acquiring HIV per sex act when compared with circumcised men. They conclude as follows:

"Moreover, our results strengthen the substantial body of evidence suggesting that variation in the prevalence of male circumcision may be a principal contributor to the spread of HIV-1 in Africa."

At the 2006 Conference on Retroviruses and Opportunistic Infections Quinn et al presented their study, conducted in Rakai, Uganda, which observed a 30% reduction in male-to-female HIV transmission, suggesting some protective effect for the female partner.

Newell and Bärnighausen (2007) also stated there was "firm evidence that the risk of acquiring HIV is halved by male circumcision."

Mishra et al. (2006) used data collected from the Demographic and Health Surveys and found that HIV prevalence was "considerably higher in urban areas and for women, especially at younger ages. Adults in wealthier households, in polygamous unions, being widowed/divorced/separated, having multiple sex partners, and having reported STIs had higher HIV rates than other adults. No consistent relationship between male circumcision and HIV risk was observed in most countries."

Way et al. (2006) also used data from Demographic and Health Surveys in Burkina Faso, Cameroon, Ghana, Kenya, Lesotho, and Malawi and from AIDS Indicator Surveys in Tanzania and Uganda to conduct his study. They found that "With age, education, wealth status, and a number of sexual and other behavioral risk factors controlled statistically, in only one of the eight countries were circumcised men at a significant advantage. In the other seven countries, the association between circumcision and HIV status was not statistically significant for the male population as a whole."

Garenne (2006) has doubts circumcision's value in reducing HIV. and Talbott (2007), in a controversial paper stated that cross country regression data pointed to prostitution as the key factor in the AIDS epidemic rather than circumcision. A World Health Organization AIDS Prevention Team official Tim Farley disagreed with the findings of the paper, while Chris Surridge, PLoS One's managing editor, defended its publication. In 1999 the American Medical Association had stated, "behavioral factors are far more important in preventing these infections than the presence or absence of a foreskin."

Millett et al in a study published in The Journal of Acquired Immune Deficiency Syndromes in 2007 found no association in three major US cities between circumcision and HIV infection among Latino and black men who have sex with men (MSM) . They conclude as follows: "In these cross-sectional data, there was no evidence that being circumcised was protective against HIV infection among black MSM or Latino MSM."

If proper hygienic procedures are not adhered to, the circumcision operation itself can spread HIV. Brewer et al. (2007) report, "[circumcised] male and female virgins were substantially more likely to be HIV infected than uncircumcised virgins. Among adolescents, regardless of sexual experience, circumcision was just as strongly associated with prevalent HIV infection. However, uncircumcised adults were more likely to be HIV positive than circumcised adults." They concluded: "HIV transmission may occur through circumcision-related blood exposures in eastern and southern Africa."

Men who have sex with men (MSM)

A 2008 meta-analysis of 15 observational studies, including 53,567 gay and bisexual men from the United States, Britain, Canada, Australia, India, Taiwan, Peru and the Netherlands (52% circumcised), found that the rate of HIV infection was non-significantly lower among men who were circumcised compared with those who were uncircumcised. For men who engaged primarily in insertive anal sex, a protective effect was observed, but it too was not statistically significant. Observational studies included in the meta-analysis that were conducted prior to the introduction of highly active antiretroviral therapy in 1996 demonstrated a statistically significant protective effect for circumcised MSM against HIV infection. In response to the meta-analysis by Millett et al., Vermund and Qian note that "circumcision would likely be insufficiently efficient to be universally effective in reducing HIV risk, and will have to be combined with other prevention modalities to have a substantial and sustained prevention effect."

Randomised Controlled Trials

Africa has a higher rate of HIV infection than anywhere in the world. Three randomised control trials were commissioned to investigate whether circumcision could lower the rate of HIV contraction. All 3 were conducted in Africa.

The first study to be published was named ANRS-1265. It was funded by the French government’s research agency, Agence Nationale de Recherches sur la SIDA (ANRS) and carried out in Orange Farm, Gauteng in South Africa. The purpose was to test the effect of adult male circumcision on HIV acquisition. The principal investigator was Dr. Bertran Auvert of Versailles University. The study enrolled 3,274 men aged 18-24. The participants were split into 2 equal groups. One group was circumcised straight away; the other group, serving as a control, was to be circumcised 21 months later. 146 of the original participants were found to have HIV at the start of the trial - they were not excluded for fear of stigmatization. It was planned that all the men would visit the research clinic four times during this 21-month period, and that they would be tested for HIV each time. They were instructed not to have sex for six weeks after the operation, and asked at each clinic visit to provide detailed information about their sexual activity. The circumcision procedure used was the forceps-guided method [31], carried out by three local general practitioners in their surgical offices. After 17 months, 20 men had contracted HIV in the circumcised group and 49 in the control group. The trial was halted on ethical grounds. The results of the trial were published in November 2005.

The authors said, “Male circumcision provides a degree of protection against acquiring HIV infection, equivalent to what a vaccine of high efficacy would have achieved. Male circumcision may provide an important way of reducing the spread of HIV infection in sub-Saharan Africa.”

A recent analysis of the potential impact of circumcision on HIV in Africa, based upon the South African RCT, suggested that male circumcision could substantially reduce the burden of HIV in Africa, particularly in southern Africa where the existing prevalence of male circumcision is low and the existing prevalence of HIV is high. More specifically it predicted that if full coverage with MC was achieved in sub-Saharan Africa over the next ten years, MC could prevent approximately 2.0 (1.1 to 3.8) million new HIV infections over that ten year period and a further 3.7 million in the ten years after that.

The above conclusions drawn from the Orange Farm study have been criticised by Michel Garenne (2006) of the Institut Pasteur. In his critique, published on the PLoS Journal of Medicine, he concludes that: "'male circumcision should be regarded as an important public health intervention for preventing the spread of HIV' appears overstated. Even though large-scale male circumcision could avert a number of HIV infections, theoretical calculations and empirical evidence show that it is unlikely to have a major public health impact, apart from the fact that achieving universal male circumcision is likely to be more difficult than universal vaccination coverage or universal contraceptive use."

Mills and Siegfried (2006) point out that trials that are stopped early tend to over estimate treatment effects. They argued that a meta-analysis should be done before further feasibility studies are done.

The NIAID, part of the NIH, supported two further trials, conducted in Kenya and in Uganda. The primary objectives of these studies were to determine whether adult male circumcision can be administered safely, and whether it would reduce the risk of acquiring HIV infection through heterosexual contact. After an initial HIV screening and a medical exam, eligible men were randomly assigned either to receive circumcision immediately or to wait two years before circumcision. All participants were closely followed for two years to collect information about their health, sexual activity, and theirs and their partners’ attitudes about circumcision; to counsel participants in HIV prevention and safe sex practices; and to check the HIV status of the volunteer. Participants in the Kenyan study were scheduled for six visits over the two-year follow-up, compared with four visits for the Ugandan trial participants. In addition to the study visits, men enrolled in the Kenyan trial were encouraged to receive all of their outpatient health care at the study clinics, which enabled researchers to collect information on the safety of the procedure and the number of other sexually transmitted diseases the men had during follow-up.

The Kenyan trial, also known as the UNIM trial (Universities of Nairobi, Illinois and Manitoba trial), began in February 2002, in Kisumu, Kenya. It was a collaborative effort between U.S., Canadian and Kenyan researchers, lead by Dr. Robert Bailey, of the University of Illinois. Also involved were Stephen Moses, University of Manitoba, Jeckoniah Ndinya-Achola, University of Nairobi, and Kwango Agot, UNIM. The trial was funded by the NIAID and the Canadian Institutes of Health Research. This trial enrolled 2,784 men between 18 and 24 years old. The participants were assessed by HIV testing, medical examinations, and behavioural interviews during follow-ups at 1, 3, 6, 12, 18, and 24 months. The circumcision procedure used in the Ugandan trial is known as the sleeve method and takes about 30 minutes. The Ugandan trial used cauterization of the blood vessels to control bleeding and stitches to close the wound. 22 men in the intervention group and 47 in the control group had tested positive for HIV when the study was stopped on ethical grounds.

The Ugandan trial began August, 2003 in Rakai, Uganda, with 4,996 men aged between 15 and 49 years old. It was led by Drs. Ronald Gray and Maria Wawer of Johns Hopkins Bloomberg School of Public Health and Drs. David Serwadda and Nelson Sewankambo of Makerere University in Kampala, Uganda. The circumcision procedure used in the Kenyan trial was the foreskin clamp method. The Kenyan trial procedure took about 25 minutes and used stitches to control bleeding and improve wound closure. Trained and certified physicians performed the circumcisions in well-equipped operating rooms. Post-operative follow-up visits were scheduled at 24-48 hours, 5-9 days, and 4-6 weeks. HIV testing, physical examination, and interviews were repeated at 4-6 weeks, 6-, 12-, and 24-month follow-up visits. After 24 months, 964 of the original 2387 men of the circumcised men had been retained of whom 22 had contracted HIV. 980 of the 2430 uncircumcised men had been retained of whom 45 had contracted HIV.

Both trials were stopped early on December 13, 2006 on ethical grounds after it found that those belonging to the control group had a greater number of men with HIV than the circumcised group.

On Wednesday, March 28, 2007, the World Health Organisation (WHO) and UNAIDS issued joint recommendations concerning male circumcision and HIV/AIDS. These recommendations are:

• Male circumcision should now be recognized as an efficacious intervention for HIV prevention.
• Promoting male circumcision should be recognized as an additional, important strategy for the prevention of heterosexually acquired HIV infection in men.

Kim Dickson, coordinator of the working group that authored the report, commented:

• Male circumcision "would have greatest impact" in countries where the HIV infection rate among heterosexual males is greater than 15 percent and fewer than 20 percent of males are circumcised.
• WHO further recommends that the procedure must be done by a trained physician.
• Protection is incomplete and men must continue to use condoms and have fewer partners.
• Newly circumcised men should abstain from sex for at least six weeks.

The World Health Organization (WHO) said: “Although these results demonstrate that male circumcision reduces the risk of men becoming infected with HIV, the UN agencies emphasize that it does not provide complete protection against HIV infection. Circumcised men can still become infected with the virus and, if HIV-positive, can infect their sexual partners. Male circumcision should never replace other known effective prevention methods and should always be considered as part of a comprehensive prevention package, which includes correct and consistent use of male or female condoms, reduction in the number of sexual partners, delaying the onset of sexual relations, and HIV testing and counselling.”

Others have also expressed concern that some may mistakenly believe they will be fully protected against HIV through circumcision and see circumcision as a safe alternative to other forms of protection, such as condoms.

Dowsett et al. urged caution over using cirumcision as a HIV prevention strategy saying that there were still questions that needed to be answered: "We need to investigate the effects of those other social and contextual factors that will be in play in real world settings – because the effectiveness of male circumcision will not be generated by the efficacy of the surgery alone." He contrasts the preventative effect of cirucmcision taken from the RCT's (55%) with the preventative effect of condoms (80-90%). He criticises the fact that the trials were not double-blinded - the participants knew there circumcision status and so this could have affected how the men responded behaviourally, psychologically and sexually. He criticised the randomisation measures used in the trial: sexual practices (number of partners, condom use) and sexual health measures (presence of STIs), saying that "Effective measures were not used, and differences related to sexual subjectivity, such as sexual network participation, pleasure preferences, body image, sexual history effects (e.g. abuse), partner preferences (younger, older, peers, groups) and so onwere never assessed or analysed." He also asks how might the extensive counselling and education have influenced the participants sexual activity. He adds that "all participants were subject to regular monitoring (e.g. behaviour surveys, clinical check-ups), which clearly might have enhanced compliance with suggested safety regimes and lowered risk-taking during the follow-up period. Such compliance cannot be guaranteed in real world settings." He also said the trials were subject to the Hawthorne effect.

An interim analysis from the Rakai Health Sciences Program in Uganda suggested that newly circumcised HIV positive men may be more likely to spread HIV to their female partners if they have sexual intercourse before the wound is fully healed. “Because the total number of men who resumed sex before certified wound healing is so small, the finding of increased transmission after surgery may have occurred by chance alone. However, we need to err on the side of caution to protect women in the context of any future male circumcision programme,” said Dr Maria Wawer, the study's principal investigator.

Kalichman et al (2007) argue that any protective effects cirucmcision could offer would be partially offset by increased HIV risk behavior, or “risk compensation" including reduction in condom use or increased numbers of sex partners. They note that circumcised men in the South African trial had 18% more sexual contacts than circumcised men at follow-up. They also said that because participants were given ongoing risk-reduction counseling and free condoms, it "reduced the utility of these trials for estimating the potential behavioral impact of male cirucmcision when implemented in a natural setting." They also criticised current models for failing to account for increased HIV risk behaviour. Increased HIV risk behaviour would mean more women would be infected which would consequntly increase the risk of men. It would also mean that non-HIV STI's, which have been assoiated with increased HIV risk, would increase.

Published meta-analyses, using data from the RCTs, have estimated the summary relative risk at 0.42 (95% CI 0.31-0.57), 0.44 (0.33-0.60) and 0.43 (0.32-0.59). (rate of HIV infection in circumcised divided by rate in uncircumcised men). Weiss et al. report that meta-analysis of "as-treated" figures from RCTs reveals a stronger protective effect (0.35; 95% CI 0.24-0.54) than if "intention-to-treat" figures are used. Byakika-Tusiime also estimated a summary relative risk of 0.39 (0.27-0.56) for observational studies, and 0.42 (0.33-0.53) overall (including both observational and RCT data). Weiss et al. report that the estimated relative risk using RCT data was "identical" to that found in observational studies (0.42). Byakika-Tusiime states that available evidence satisfies six of Hill's criteria, and concludes that the results of her analysis "provide unequivocal evidence that circumcision plays a causal role in reducing the risk of HIV infection among men." Mills et al. conclude that circumcision is an "effective strategy for reducing new male HIV infections", but caution that consistently safe sexual practices will be required to maintain the protective effect at the population level. Weiss et al. conclude that the evidence from the trials is conclusive, but that challenges to implementation remain, and will need to be faced.

Langerhans cells and HIV transmission

Langerhans cells are part of the human immune system. Three studies identified high concentrations of Langerhans and other "HIV target" cells in the foreskin and Szabo and Short suggested that the Langerhans cells in the foreskin may provide an entry point for viral infection. McCoombe, Cameron, and Short also found that the keratin is thinnest on the foreskin and frenulum. Fleiss, Hodges and Van Howe had previously stated a belief that the prepuce has an immunological function. While their specific hypothesis was criticised on technical grounds. A study published in 2007 by de Witte and others said that langerin, produced by Langerhans cells, is a natural barrier to HIV-1 transmission by Langerhans cells.

Dowsett (2007) questioned why it was just males that were being encouraged to circumcise: "Langerhans cells occur in the clitoris, the labia and in other parts of both male and female genitals, and no one is talking of removing these in the name of HIV prevention."

Other Sexually transmitted infections

A recent systematic review [32] has suggested that there is strong evidence for a protective effect of circumcision against Syphilis or Chancroid infection, but only weak evidence for a protective effect against Herpes Simplex.

Epididymitis

Epididymitis is inflammation of the epididymis. It can be very painful, and become a chronic condition, but medical treatment is well accepted and effective. [33] [34]. One 1998 study found the rate of epididymitis in boys with foreskins was significantly higher than in those without; that an intact foreskin is an important etiological factor in boys with epididymitis.

Hygiene

The American Academy of Pediatrics observes “Circumcision has been suggested as an effective method of maintaining penile hygiene since the time of the Egyptian dynasties, but there is little evidence to affirm the association between circumcision status and optimal penile hygiene.” It states that the "relationship among hygiene, phimosis, and penile cancer is uncertain" and further remarks that "genital hygiene needs to be emphasized as a preventive health topic throughout a patient's lifetime."

The Royal Australasian College of Physicians emphasizes that the penis of an uncircumcised infant requires no special care and should be left alone. It states that attempts to forcibly retract the foreskin, e.g. to clean it, are painful, often injure the foreskin, and can lead to scarring, infections and pathologic phimosis. Non-circumcised men are told not to wash with soap as it can inflame the penis.

Smegma is a combination of exfoliated epithelial cells, transudated skin oils, and moisture that can accumulate under the foreskin of males and within the female vulva area. It is common to all mammals—male and female. In rare cases, accumulating smegma may help cause balanitis.

Hutson speculated that circumcision arose in peoples living in arid and sandy regions as a public health measure intended to prevent recurring irritation and infection caused by sand accumulating under the foreskin. Darby, after checking the official war histories of Britain, Australia and New Zealand and other records, and finding no mention of ‘balanitis’ or ‘foreskin’ or ‘circumcision’, dismissed this idea as a “medical urban myth,” concluding that “‘sand under the foreskin,’ balanitis, and circumcision were not significant problems during either of the World Wars.”

Lerman and Liao (2001) state that apart from its effects on UTI rates, "Most of the other medical benefits of circumcision probably can be realized without circumcision as long as access to clean water and proper penile hygiene are achieved."

Local infection and inflammation

A 1988 New Zealand study of penile problems by Fergusson et al, in a birth cohort of more than 500 children from birth to 8 years of age found that:

By 8 years, circumcised children had a rate of 11.1 problems per 100 children, and uncircumcised children had a rate of 18.8 per 100. The majority of these problems were for penile inflammation including balanitis, meatitis, and inflammation of the prepuce. However, the relationship between risks of penile problems and circumcision status varied with the child's age. During infancy, circumcised children had a significantly higher risk of problems than uncircumcised children, but after infancy the rate of penile problems was significantly higher among the uncircumcised. These associations were not changed when the results were adjusted statistically for the effects of a series of potentially confounding social and perinatal factors. [35]

The authors of this study acknowledged certain problem with the data:

It is important to recognize that the data on medical attendance for penile problems was collected as part of a much larger longitudinal study of child health and development in which the primary concern was not with the issue of the longterm consequences of circumcision. This feature of the data collection process places a number of restrictions on the quality of the collected data. Specifically, data relating to immediate postcircumcision problems and penile problems that were treated at home without medical attention were not available. Also, diagnostic details of medical attendances for penile problems were limited. The net result of these imprecisions in the data collection process is that the incidence and prevalence of penile problems probably underestimated and the problems can only be described in terms of broad diagnostic categories. Nonetheless, we believe that the trends that emerge from the analysis are likely to reflect general differences in the medical histories of circumcised and uncircumcised children.[36]

Van Howe observed that Fergusson et al. used parental complaints rather than direct examination in their retrospective study, so the study may have understated the number of boys with penile problems.[37]

Studies have found that boys with foreskins tend to have higher rates of various infections and inflammations of the penis than those who are circumcised. The reasons are unclear, but several hypotheses have been suggested:

• The foreskin may harbor bacteria and become infected if it is not cleaned properly.
• The foreskin may become inflamed if it is cleaned too often with soap.
• The forcible retraction of the foreskin in boys can lead to infections.

Some mothers believe that circumcision will relieve them and the child of the bother of cleanliness, however Patel (1966) insists this is incorrect.

Balanitis

Main article: Balanitis

Balanitis, an inflammation of the glans penis, has several causes. Some of these, such as anaerobic infection, occur more frequently in uncircumcised men. Balanitis involving the foreskin is called balanoposthitis. The usual treatment for balanoposthitis is to use topical antibiotics (metronidazole cream) and antifungals (clotrimazole cream) or low-potency steroid creams. One study found that uncircumcised men had more than five times the rate of balanitis [38]. The most common complication of balanitis is phimosis, or inability to retract the foreskin from the glans penis.[39].

EMedicine says: "Uncircumcised men with poor personal hygiene are most affected by balanitis. Lack of aeration and irritation because of smegma and discharge surrounding the glans penis causes inflammation and edema. Adherence of the foreskin to the inflamed and edematous glans penis causes phimosis."[40] O'Farrell et al. noted inferior hygiene among uncircumcised men attending a sexually transmitted infections (STI) clinic at Ealing Hospital, London.[41] The researchers also reported an association between balanitis and inferior hygiene.

Balanitis has many causes, including irritation by environmental substances, physical trauma, and infection by a wide variety of pathogens, including bacteria, virus, yeast, or fungus — each of which require a particular treatment. Good medical practice includes careful diagnosis with the aid of a good patient history, swabs and cultures, and pathologic examination of a biopsy. Only then can the proper treatment be prescribed.[42] Many studies of balanitis do not examine the subjects' genital washing habits. A 1993 study by Birley et al. did so and found that excessive genital washing with soap may be a strong contributing factor to balanitis.

Fakjian et al. studied 398 patients at a dermatology clinic in a cross-sectional study. 213 (53.5%) had been circumcised. "Balanitis was diagnosed in 2.3% of circumcised men and in 12.5% of uncircumcised men. In patients with diabetes mellitus, balanitis occurred with a prevalence of 34.8% in the uncircumcised population, compared with 0% in the circumcised population. Balanitis did occur with increased frequency in the diabetic population (16%), regardless of circumcision status, compared with the nondiabetic population (5.8%)." [43]

Treatments that are less invasive than circumcision are effective in treating most mild cases of balanitis. Birley, et al, found that in 90% of their cases of chronic or recurring balanitis "use of emollient creams and restriction of soap washing alone controlled symptoms satisfactorily". They also state that circumcision “might be of benefit in a patient whose balanitis relapses despite these measures, and remains the principal treatment for specific conditions such as lichen sclerosus and plasma cell balanitis.” The, less invasive procedures are not as successful in treating balanitis xerotica obliterans, or BXO, which is much less common but harder to treat. Balanitis xerotica obliterans is a skin condition causing white, atrophic patches on the glans or foreskin. It is much more common among uncircumcised males. Circumcision is believed to reliably reduce the threat of BXO.

Balanitis in childhood. Balanitis afflicts young boys generally only where a difficult to retract tight foreskin is present. Two studies found that uncircumcised boys were at approximately twice the risk of developing balanitis[44][45] Escala and Rickwood, in a 1989 examination of 100 cases of balanitis in childhood, concluded: "[T]he risk in any individual, uncircumcised boy appears to be no greater than 4%." [46], They recommend circumcision as a last resort only in cases of recurrent balanitis.[47]

Images of balanitis [48] [49] [50]

Urinary tract infection (UTI)

Infections of the urinary tract (kidneys, ureters, bladder and urethra) can generally be treated effectively with antibiotics, in rare cases it can lead to more serious conditions.

Singh-Grewal (2005) performed a meta-analysis of 12 studies (one randomised controlled trial, four cohort studies, and seven case–control studies) looking at the effect of circumcision on the risk of urinary tract infection (UTI) in boys. Circumcision was associated with a reduced risk of UTI (OR = 0.13; 95% CI, 0.08 to 0.20; p<0.001). The authors found that the number of circumcisions (number needed to treat) to prevent one infection was 111.

Some of the studies done to investigate the effect circumcision has on incidence of UTI have been extensively criticized for their methodology. The American Academy of Pediatrics noted in its 1999 circumcision policy statement:

Few of the studies that have evaluated the association between UTI in male infants and circumcision status have looked at potential confounders (such as prematurity, breastfeeding, and method of urine collection) in a rigorous way. For example, because premature infants appear to be at increased risk for UTI, the inclusion of hospitalized premature infants in a study population may act as a confounder by suggesting an increased risk of UTI in uncircumcised infants. Premature infants usually are not circumcised because of their fragile health status. In another example, breastfeeding was shown to have a threefold protective effect on the incidence of UTI in a sample of uncircumcised infants. However, breastfeeding status has not been evaluated systematically in studies assessing UTI and circumcision status.

A 1998 Canadian population based cohort study by To et al. reported a relative risk of 3.7. The overall incidence of UTIs in infants was low, 1.88 and 7.02 per 1000 respectively. Based upon their data, To et al. estimate that 195 circumcisions would be needed to prevent one hospital admission for UTI in the first year of life.

The American Medical Association cites evidence that the incidence of UTI’s is “small (0.4%–1%)” in uncircumcised infants, and “depending on the model employed, approximately 100 to 200 circumcisions would need to be performed to prevent 1 UTI…One model of decision analysis concluded that the incidence of UTI would have to be substantially higher in uncircumcised males to justify circumcision as a preventive measure against this condition.” According to the American Medical Association, "There is little doubt that the uncircumcised infant is at higher risk for urinary tract infection (UTI)."

Jakobsson et al. (1999) found that the mean diagnostic rate of the first UTI in children under 2 years of age was 1.5%; the mean incidence was 1.0%; and the cumulative incidence at 2 years of age was estimated at 2.2%.

Nayir (2001) conducted a study in Turkey to contrast the effects of circumcision and antibiotics on bacteriuria. He split 70 uncircumcised boys into 2 equal groups. One group was circumcised immediately, the other treated with antibiotics. The circumcised group were found to have a lower rate of bacteriuria per patient. Newman (2002) found that lack of circumcision was associated with a UTI. Cason et al (2000) investigated the effect of circumcision on recurrent UTI. 744 male infants were admitted to the hospital's neonatal intensive care unit, of these 38 infants had UTI's. None of the premature infants in the study had a recurrent UTI once a circumcision was performed. Schoen et al (2000) found that of the 14,893 male infants born during 1996 in 12 KPNC (Kaiser Permanente Medical Care Program of Northern California) hospitals, 154 cases of UTI occurred in boys under 1 year of age. Of these, 138 were uncircumcised. The most prominent organism found was E coli. They concluded that in the first year of life non-circumcised boys have a higher incidence of UTI.

Mueller et al. (1997) investigated the contribution of underlying genitourinary (GU) structural abnormalities to UTI. It found that regardless of circumcision status infants who present with a UTI in the first 6 months of life are more likely to have an underlying genitourinary (GU) structural abnormality. In the remaining patients with normal underlying anatomy and UTI there were as many circumcised infants as those who retained their foreskin.

UTIs are usually detected through urine tests. Depending on the method of urine collection, there is a varying risk of false positives through contamination. The bacteria detected may in fact come from the foreskin itself, not the urinary tract. In spite of this, an increased risk of UTI in uncircumcised males is generally considered plausible, a higher likelihood of bacterial colonization being the proposed mechanism.

The Canadian Paediatric Society questions whether increased UTI and balanitis rates in uncircumcised male infants may be caused by forced premature retraction. Cunningham also mentioned this in response to an early study by Wiswell, Smith and Bass. Hodges and Fleiss claim that "it has been proven that retraction and washing of the infant foreskin can cause urinary tract infections by irritating the mucous membranes and destroying the naturally occurring beneficial flora which protects against pathogens." Some contend that fewer pathogens are present in circumcised males.

A 2008 retrospective analysis by Roth et al. found no statistically significant difference between circumcision status and the incidence of UTI in boys who had upper urinary tract obstructions.

Skin conditions

Researchers from the Imperial College School of Medicine, Chelsea & Westminster Hospital, London, England in a study Circumcision and genital dermatosesreported the results of their study of 357 patients referred for genital skin disease:

Most cases of inflammatory dermatoses were diagnosed in uncircumcised men, suggesting that circumcision protects against inflammatory dermatoses. The presence of the foreskin may promote inflammation by a koebnerization phenomenon, or the presence of infectious agents, as yet unidentified, may induce inflammation. The data suggest that circumcision prevents or protects against common infective penile dermatoses.

Some American military doctors have recommended prophylactic circumcision because of the difficult conditions during wartime. For example, a United States Army report regarding World War II noted that in case of penile lesions, the foreskin may "invite secondary infection". The sexually transmitted disease chancroid, now very uncommon, was also associated with phimosis, which could hardly occur in circumcised males, and "soldiers in combat were seldom able to practice personal hygiene". (Source: JF Patton, Medical Department, United States Army, Surgery in World War II, Urology, p. 64)

There are a few cases of skin diseases such as staphyloccal scalded skin syndrome or impetigo following circumcision. [51][52]. One study found a difference in infection rates between circumcised and uncircumcised boys (p < 0.10) that was not statistically significant, "perhaps due to the relatively small number.." . [53]

Lichen sclerosus et atrophicus (LSA) produces a whitish-yellowish patch on the skin, and is not believed to be always harmful or painful, and may sometimes disappear without intervention. Some consider balanitis xerotica obliterans to be a form of LSA that happens to be on the foreskin, where it may cause pathological phimosis.

Zoon's Balanitis, illustrated here [54], also know as Balanitis Circumscripta Plasmacellularis or plasma cell balanitis (PCB) is an idiopathic, rare, benign penile dermatosis, usually of a middle-aged or older man [55]. Circumcision is the usual treatment of choice but fusidic acid cream 2% has been curative in some cases. [56] [57]

Phimosis

Phimosis is the inability to retract the prepuce over the glans penis after separation from the glans has occurred. The foreskin is joined to the glans, and is naturally unretractable when a baby is born. But there are differences of opinion about how long this should continue, and how the foreskin should be treated if it remains too tight for too long. Gairdner[58] published data regarding the age of first foreskin retraction in 1949 that is now thought by some to be incorrect. However, these data are still presented in medical textbooks and taught in medical schools.[59] Many doctors, therefore, are misinformed about the natural development of the foreskin, and this contributes to the mis-diagnosis of the normal non-retractile foreskin of childhood as pathological disease. Rickwood and Walker (1989) raised concern that phimosis is frequently misdiagnosed by physicians confusing it with the developmentally non-retractable foreskin., and Rickwood et al. write in their 2000 paper "Towards evidence based circumcision of English boys" in the British Medical Journal [60]:

Too many English boys, especially those under 5 years of age, are still being circumcised because of misdiagnosis of phimosis. What is phimosis? At birth, the foreskin is almost invariably non-retractable, but this state is transient and resolves in nearly all boys as they mature through puberty. Such normality, with an unscarred and pliant preputial orifice, is clearly distinguishable from pathological phimosis, a condition unambiguously characterised by secondary cicatrisation of the orifice, usually due to balanitis xerotica obliterans. This problem, the only absolute indication for circumcision, affects some 0.6% of boys, peaks in incidence at 11 years of age, and is rarely encountered before the age of 5. (…) Strictly, only some 0.6% of boys with pathological phimosis need to be circumcised, although more relaxed criteria would allow for a similar proportion affected by recurrent balanoposthitis.

A 1968 Danish study of 9,545 boys, which distinguished between phimosis and preputial adhesion, found that both conditions steadily declined with age. Phimosis was 8% among 6-7 year olds but only 1% among 16-17 year olds. Similarly, preputial adhesion was 63% among 6-7 year olds but only 3% among 16-17 year olds. The author, Jakob Øster, concluded:

Phimosis is seen to be uncommon in schoolboys, and the indications for operation even rarer if the normal development of the prepuce is patiently awaited. When this policy is pursued, in the majority of cases of phimosis, it is seen to be a physiological condition which gradually disappears as the tissues develop. [61]

It has been observed that Øster's study may not be representative of wider populations. [62] The true incidence of phimosis is controversial. Osmond found that 14% of British soldiers had phimosis, and Schoeberlein noted that 9.2% of uncircumcised German men had phimosis[63]. Reporting on a New Zealand study, Fergusson et al found that 3.7% of boys had phimosis, while Herzog and Alvarez found it in 2.6%. [64] Dawson and Whitfield, say "True phimosis is rare but may cause appreciable problems in either childhood or adolescence."[65] The AAP state that the true frequency of problems such as phimosis is unknown.

Several researchers have described less invasive treatments for phimosis than circumcision, and recommend that they be tried first. Several studies have identified phimosis as a risk factor for penile cancer. A letter to the British Medical Journal stated it would be irresponsible to expose a patient to risk for longer than necessary.

Phimosis is also a complication of circumcision, that can occur when too little foreskin is removed.[66]

Images of phimosis.[67][68][69]

Paraphimosis

The American Academy of Family Physicians says:

"Paraphimosis is a urologic emergency, occurring in uncircumcised males, in which the foreskin becomes trapped behind the corona and forms a tight band of constricting tissue. Often iatrogenically induced, paraphimosis can be prevented by returning the prepuce to cover the glans following penile manipulation. Treatment often begins with reduction of edema, followed by a variety of options, including mechanical compression, pharmacologic therapy, puncture technique and dorsal slit. Prevention and early intervention are key elements in the management of paraphimosis. (Am Fam Physician 2000;62:2623-6,2628.)"[70]

The article goes on to say that the cause is most often iatrogenic (caused by doctors). It further stated:

"Rare causes of paraphimosis include self-inflicted injury to the penis (such as piercing a penile ring into the glans) and paraphimosis secondary to penile erections."

In children, it is sometimes caused by a caregiver trying to forcibly retract the infant foreskin.

Several techniques to treat paraphimosis are listed in an article in the American Family Physician, and in the anti-circumcision web site CIRP. [71] One procedure is minor surgery to make a small slit in the foreskin without removing any tissue.[72] Another is called the "Dundee technique." [73] The Royal Children's Hospital in Melbourne, Australia, says, "Once reduced, a single episode of paraphimosis is not an indication for circumcision." [74] but an article in the American Family Physician says that paraphimosis is one of the medical indications for circumcision [75].

Images of paraphimosis. [76][77]

Costs and benefits

The American Academy of Pediatrics (1999) said:

"Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision. In the case of circumcision, in which there are potential benefits and risks, yet the procedure is not essential to the child's current well-being, parents should determine what is in the best interest of the child." Policy Statement, 1999

Clarifying their statement in 2000, the authors explained:

The Task Force found the evidence of low incidence, high-morbidity problems not sufficiently compelling to recommend circumcision as a routine procedure for all newborn males. However, the Task Force did recommend making all parents aware of the potential benefits and risks of circumcision and leaving it to the family to decide whether circumcision is in the best interests of their child.…Circumcision falls into that group of procedures that have potential medical benefits and some risks and should be evaluated by each family in the context of their personal beliefs and values as well as their ethnic, cultural, and religious practices. The Task Force respects the role of parents as decision-makers for their newborns and recommends that physicians discuss with parents the potential benefits as well as risks of circumcision so that parents can decide whether circumcision is in the child's best interests.

In June 2004 the College of Physicians and Surgeons of British Columbia said:

"Infant male circumcision was once considered a preventive health measure and was therefore adopted extensively in Western countries. Current understanding of the benefits, risks and potential harm of this procedure, however, no longer supports this practice for prophylactic health benefit. Routine infant male circumcision performed on a healthy infant is now considered a non-therapeutic and medically unnecessary intervention."[78]

Several cost-benefit analyses of infant circumcision have been published.

Cadman et al. (1984) concluded that the expense of circumcision outweighed any money that might be saved by reducing the risk of penile cancer. Therefore, they argued, public funds should not pay for it [79].

Lawler et al. (1991) [80] reported a net cost of $25.00 and a benefit of ten days of life. They concluded that there was no medical indication for or against circumcision.

Ganiats et al. (1991) [81] reported a net cost of $102 and a loss of 14 hours of healthy life. They found no medical reason to recommend for or against circumcision.

Chessare (1992) weighed the risks of circumcision against the prevention of urinary tract infections [82]. He concluded that non-circumcision produced the “highest expected utility”, provided that the probability of developing a UTI was less than 0.29%.

Christakis et al. (2000) report that "Circumcision remains a relatively safe procedure. However, for some parents, the risks we report may outweigh the potential benefits." [83]

Van Howe (2004) reported that the overall effect of male neonatal non-therapeutic circumcision on health is more likely to be negative rather than positive.

Schoen et al. (2006) concluded: "Multiple lifetime medical benefits of neonatal circumcision can be achieved at little or no cost. Because postneonatal circumcision is so expensive, its rate is the most important factor determining future cost savings from newborn circumcision."

Singh-Grewal et al. compared reduction in risk of urinary tract infections with an estimated 2% complication rate, and concluded: "Haemorrhage and infection are the commonest complications of circumcision, occurring at rate of about 2%. Assuming equal utility of benefits and harms, net clinical benefit (of circumcision) is likely only in boys at high risk of UTI." In an accompanying editorial, Schoen argued that the 2% complication rate used by Singh-Grewal et al. was high, noting that the American Academy of Pediatrics estimated the rate as 0.2% to 0.6%.

Some public and private health insurance providers have deleted coverage of elective non-therapeutic circumcision. In such cases, the cost falls on the person electing the procedure.

See also

• Bioethics of neonatal circumcision
• Circumcision advocacy
• Genital integrity (opponents of circumcision)
• Circumcision and law
• Foreskin
• Foreskin restoration
• Male circumcision
• Female circumcision

References

Some referenced articles are available on-line only in the Circumcision Information and Resource Page’s (CIRP) library or in The Circumcision Reference Library (CIRCS). CIRP articles are chosen from an anti-circumcision point of view, and text in support of this position is often highlighted on-screen using HTML. CIRCS articles are chosen from a pro-circumcision point of view. If documents are not freely available on-line elsewhere, links to articles in one or other of these two websites may be provided.

Further reading

• Apt A. Circumcision and prostatic cancer. Acta Med Scand 1965; 178: 493-504.
• Bailis, S. & Halperin, D.. Male circumcision: time to re-examine the evidence. studentBMJ May 2006;14:179-180.
• Reddy DG, Baruah IK. Carcinogenic Action of Human Smegma. Arch Pathol 1963; 75(4): 414-420.

External links

• American Academy of Pediatrics. Circumcision Policy Statement (RE9850). March 1999.
• American Medical Association. Report 10 of the Council on Scientific Affairs (I-99), Neonatal Circumcision. Dec 1999.
• British Medical Association. The Law & Ethics of Male Circumcision - Guidance for Doctors. March 2003.
• Canadian Paediatric Society. Neonatal Circumcision Revisited. 1996 (reaffirmed March 2002)
• The Royal Australasian College of Physicians. Policy Statement On Circumcision. Sep 2002.
• Remondino, Peter Charles. History of Circumcision from the Earliest Times to the Present. Philadelphia and London; F. A. Davis; 1891.