Medical analysis of circumcision


Medical analysis of circumcision

Numerous medical studies have examined the effects of male circumcision with mixed opinions regarding the benefits and risks of the procedure. Opponents of circumcision say it is medically unnecessary, is unethical when performed on newborns, is painful even when performed with anesthetic, adversely affects sexual pleasure and performance, and is a practice defended by myths.[1] Advocates for circumcision say it provides important health advantages which outweigh the risks, that it improves on sexual function,[2] has a complication rate of less than 0.5% when carried out by an experienced physician, and is best performed during the neonatal period.[3]

The Royal Dutch Medical Association stated in 2010: "There is currently not a single doctors' organisation that recommends routine circumcision for medical reasons."[4]

The World Health Organization (WHO; 2007), the Joint United Nations Programme on HIV/AIDS (UNAIDS; 2007), and the Centers for Disease Control and Prevention (CDC; 2008) state that evidence indicates male circumcision significantly reduces the risk of HIV acquisition by men during penile-vaginal sex, but also state that circumcision only provides partial protection and should not replace other interventions to prevent transmission of HIV.[5][6]

Contents

Positions of major health organizations

Australasia

The Royal Australasian College of Physicians (RACP; 2009) state that "after extensive review of the literature" they "[do] not recommend that routine circumcision in infancy be performed". They also state that "if the operation is to be performed, the medical attendant should ensure this is done by a competent surgeon, using appropriate anaesthesia and in a safe child-friendly environment." Additionally, the RACP state that there is an obligation to provide parents who request a circumcision for their child with accurate, up-to-date and unbiased information about the risks and benefits of circumcision, adding that "in the absence of evidence of substantial harm, parental choice should be respected."[7]

Canada

The Fetus and Newborn Committee of the Canadian Paediatric Society posted "Circumcision: Information for Parents" in November 2004,[8] and "Neonatal circumcision revisited" in 1996. The 1996 position statement says that "circumcision of newborns should not be routinely performed", and the 2004 advice to parents says it "does not recommend circumcision for newborn boys. Many paediatricians no longer perform circumcisions."[9]

Netherlands

The Royal Dutch Medical Association issued a new policy in May 2010: "The official viewpoint of KNMG and other related medical/scientific organisations is that non-therapeutic circumcision of male minors is a violation of children’s rights to autonomy and physical integrity. Contrary to popular belief, circumcision can cause complications – bleeding, infection, urethral stricture and panic attacks are particularly common. KNMG is therefore urging a strong policy of deterrence. KNMG is calling upon doctors to actively and insistently inform parents who are considering the procedure of the absence of medical benefits and the danger of complications."[4]

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.”[10]

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, "In the pluralistic society of the United States in which parents are afforded wide authority for determining what constitutes appropriate child-rearing and child welfare, it is legitimate for the parents to take into account cultural, religious, and ethnic traditions, in addition to medical factors, when making this choice." 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.[11]

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[12]

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.[13]

The American Urological Association (May 2007) states there are benefits and risks to circumcision, recommending that circumcision "should be presented as an option for health benefits" while acknowledging that "[e]vidence associating neonatal circumcision with reduced incidence of sexually transmitted diseases is conflicting." It feels that parents should consider medical benefits and risks, and ethnic, cultural, etc. factors when making this decision.[14]

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." [15]

Clarifying their statement in 2000 in response to criticism by Schoen et al.,[16] 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.[17]

Schoen et al. further replied in a letter to the editor, still disagreeing, and arguing that the task force had not given enough consideration to benefits of circumcision.[18]

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."[19]

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.[20]
  • Lawler et al. (1991) 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.[21]
  • Ganiats et al. (1991) 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.[22]
  • Chessare (1992) weighed the risks of circumcision against the prevention of urinary tract infections.[23] 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."[24]
  • 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.[25] Van Howe is a fierce opponent of circumcision. In 1999 a detractor accused him of bias, distortions and misrepresentation of the literature.[26]
  • 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."[27] E.J. Schoen is an 'outspoken proponent' of circumcision.[citation needed]
  • 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 [a] 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."[28] 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%.[29]

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.

Circumcision procedures

A circumcised penis

Circumcision removes the foreskin from the penis. For infant circumcision, clamps, such as the Gomco clamp, Plastibell, are often used.[30] Clamps cut the blood supply to the foreskin, stop bleeding and protect the glans. Before use of 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 protects the glans from the scalpel.[31]
  • 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," according to Reynolds, 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.[32][33]

The frenulum may be cut if frenular chordee is evident.[34][35]

Potential complications

Williams & Kapila state: "the literature abounds with reports of morbidity and even death as a result of circumcision."[36] Complications may be immediate or delayed, and complications from bleeding, infection and poorly carried out circumcisions can be catastrophic.[37] 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%,[12] based on the studies of Gee[38] and Harkavy.[39] These same studies are quoted by the American Academy of Pediatrics.[15] The American Academy of Family Physicians quotes a range of anywhere between 0.1% and 35%.[40] The Canadian Paediatric Society cites these results in addition to other figures ranging anywhere between 0.06% to 55%, and remark that Williams & Kapila[36] suggested that 2-10% is a realistic estimate.[41] The RACP states that the penis is lost in 1 in 1,000,000 circumcisions.[42]

Deaths have been reported.[43][44] The American Academy of Family Physicians states that death is rare. It estimates a death rate from circumcision of 1 infant in 500,000.[40] 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.[45]

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.[46]

Immediate Complications

According to the AMA, blood loss and infection are the most common complications, but most bleeding is minor and can be stopped by applying pressure.[12] 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.”[43]

  • Infection
Infections are usually minor and local, but sometimes they have led to urinary tract infection,[47] life-threatening systemic infections,[48] meningitis[49] or death.[50]
Staphylococcal infections are a growing problem in hospitals for any operation,[51][52] and MSSA (methicillin susceptible) [53] strains of s.aureus have affected neonatal nurseries. Some research has found a statistically significant correlation between golden staph (Staphylococcus aureus) infections and whether an infant has been circumcised[54][55] 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."[56]
Images of an infant with a life-threatening s.aureus infection may be found here[48]
  • Herpes
A minority of Jewish circumcisers practise Metzitzah b'peh, (oral suction). Three published medical papers have suggested a link between metzitzah bipeh and neonatal herpes in two cases in New York,[57] 8 cases in Israel and one in Canada,[58][59] one of whom suffered brain damage.[60] 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.[61] In response to this, New York public health officials warned the Jewish community about the dangers of metzizah b'peh.[62]
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.[59]
The New York City Department of Health and Mental Hygiene (NYC Dept of Health) 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.[62] (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, pushed for the passage of the NYS protocol for the performance of metzitzah b'peh,[63] requiring DNA testing of at least four persons, including the parents, if a baby gets herpes following ritual circumcision that includes oral suctioning of the wound. It is worth noting that 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, no cases have been reported. The NYC Dept of Health, wishing to further investigate potential cases of neonatal herpes that they believed the ultra-orthodox were hiding, pushed to have neonatal herpes made a reportable disease in NYC in 2006[64] and found no cases. A few months later they pushed New York State, which would include the large Chassidic enclaves of Kiras Joel, New Square, and Monsey to declare the disease reportable, and found no cases. In order to broaden the scope of surveillance, Asst NYC DoH Commissionor Dr. Julia Schillinger added another ICD classification to her investigation and found no cases. Unconvinced that the Chassidim were reporting cases of herpes, Dr. Schillinger conducted a retrospective review of all NYC hospital discharge records coded ICD 054. or 772.1 from 1994 to 2003[65] and did not find any cases. Despite having delivered a dissertation at the 2006 National STD prevention conference in Jacksonville, FL confirming that the majority of neonatal herpes present to treatment between 8 and 20 days like all the published cases and all the city's cases except one, however in contrast to a paper co-authored by Dr. Schillinger and delivered by Shoshana Handel[66] at the 2007 Seattle ISSTDR convention confirming that 39% (2 out of 5) cases of neonatal herpes were HSV-1, and 2 out three NHSV fatalities were HSV-1 (female) Dr. Schillinger still maintains that the timing and HSV-1 would implicate the mohel as the source in those cases.


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.[67]

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).[68]

Coagulation disorders affect from 2 to 4 per cent of the population and the condition is underdiagnosed.[69] Severe bleeding following circumcision may be a sign of hemophilia.[70]

  • Surgical mishap
Mistakes can happen with any surgery. Surgical mistakes from circumcision include documented cases of penile denudation,[71] cutting off part or all of the glans penis,[72] urethral fistula,[73] several types of injury associated with certain types of circumcision clamps used[74] and penile necrosis which results in loss of the entire penis.
  • Anesthetic risk
Anesthetic risk includes Methemoglobinemia.[75]

Delayed Complications

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.[88] A literature review by Gerharz and Haarmann (2000) reached a similar conclusion.[89] 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.[90] Boyle et al. (2002) state that circumcision may result in psychological harm, including post-traumatic stress disorder (PTSD), citing a study that shows an incidence rate of PTSD (measured according to DSM-IV) of almost 70% among Filipino boys subjected to ritual circumcision, and 51% among boys subjected to medical circumcision (with local anaesthetic).[91] Hirji et al. (2005) state that "Reports of [...] psychological trauma are not borne out in studies but remain as an anecdotal cause for concern."[92] The British Medical Association (2006) stated that the "medical harms or benefits have not been unequivocally proven," and that "[...] it is now widely accepted, including by the BMA, that this surgical procedure has medical and psychological risks."[10]

Some organizations have formed support groups for men who are resentful about being circumcised.[1]

Pain

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.[93]
-- 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)[94] Brief and transitory effects on mother-infant interactions observed during hospital feeding sessions.
No pain relief
Howard (1994)[95] Significant increases in heart rate, respiratory rate, and crying. Deteriorated feeding behaviour.
Taddio (1997)[96] Stronger pain response during vaccination 4 to 6 months later.
Lander (1997) [97][98] 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)[95] Significant increases in heart rate, respiratory rate, and crying. Deteriorated feeding behaviour. Improved comfort after postoperative period.
Taddio (1997)[96] Stronger pain response during vaccination 4 to 6 months later, though attenuated as compared to placebo.
EMLA (topical anaesthetic)
Lander (1997)[97] Significantly less crying and lower heart rates compared with those circumcised without anaesthetic (see above).
Dorsal penile nerve block (DPNB)
Kirya (1978)[99] Circumcision pain eliminated except when the injection needle was misplaced.
Lander (1997) [97] Significantly less crying and lower heart rates than circumcision without anaesthetic. Not effective during foreskin separation and incision.
Ring block
Lander (1997) [97] 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.

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.[96] 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".[100] However, Lander et al. found that DPNB is less effective than ring block.[97]

Breastfeeding

Some advocates have hypothesized that circumcision may negatively impact breastfeeding. The most current research does not support the belief that neonatal circumcision disrupts breastfeeding.[101]

Earlier studies exploring this phenomenon include the Howard study, reporting that neonatal circumcision without anaesthesia and using acetaminophen (Tylenol) results in deteriorated feeding immediately after circumcision.[95] 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.[95]

Fergusson et al. found no evidence in their study of an association between neonatal circumcision and breastfeeding outcomes. They concluded that "the findings do not support the view that neonatal circumcision disrupts breastfeeding."[101]

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.[102] 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).[103] 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).[104] Ewings and Bowie performed a case-control study of 159 cases of prostate cancer, and found a reduced rate among circumcised men (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."[105]

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.[106]

Human Papilloma Virus (HPV)

A meta-analysis by Van Howe in 2006 found 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".[107] 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."[108]

In several studies, uncircumcised men were found to have a greater incidence of human papilloma virus (HPV) infection than circumcised men.[109][109][110][111][112] One of these studies[109] has been criticized on methodological grounds.[107][113] One study found no statistically significant difference in the incidence of HPV infection between circumcised and uncircumcised men.[114]

Two studies have shown that circumcised men report, or were found to have, a higher prevalence of genital warts than uncircumcised men.[115][116]

The Medical College of Georgia studied the impact of a new (as of 2004) vaccine against "HPV types 16 and 18, the two most common causes of cervical and penile cancer".[117]

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.[118] They also state that the current consensus of most experts is that circumcision should not be recommended as a prevention strategy for penile cancer.[119]

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.[109][120]

Stern and Neely (1962) observed no protective effect of male circumcision in female partners.[121] Punyaratabandhu et al. (1982) reported a protective effect in Thai women.[122] Kjaer et al. (1991) reported an apparently protective effect in Dutch women, that failed to achieve statistical significance.[123] Agarwal et al. (1993) observed a significantly protective effect among Indian women.[124]

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."[125]

Penile cancer

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. Annually, there is one case in 100,000 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.[126]Penile cancer is a rare form of cancer, mostly occurring in men over the age of 60.[127] 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.[128]

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.[129] However, Poland has criticised the assumptions used in their analysis.[130]

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.[131]

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.[132]

Childhood circumcision has been associated with a reduced incidence of penile cancer in numerous studies.[133][134][135][136][137][138] 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."[139] The AMA remarked that in six case series published from 1932 and 1986, "all penile cancers occurred in uncircumcised individuals."[12]

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).[140] 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 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.[141] The American Academy of Pediatrics made similar criticism, also noting the possibly inaccurate use of self-report to determine circumcision status.[15]

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.[142]

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.[136]

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.[143]

Fleiss and Hodges, together with Cold, Storms and Van Howe, suggest that the idea 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.[144][145]

Fleiss and Hodges state that epidemiological studies have failed to prove Wolbarst's assertion.[145] 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."'[146]

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.[147]

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. They stated further that penile cancer is a rare disease in developed countries and that the risk of penile cancer developing in an uncircumcised man, although increased compared with a circumcised man, remains low.[15] 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.[12]

The Royal Australasian College of Physicians stated that the use of infant circumcision to prevent penile cancer alone in adulthood is not justified.[148][dead link]

The American Cancer Society 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.[149]

HIV/AIDS

Van Howe conducted a meta-analysis in 1999 and found circumcised men at a greater risk for HIV infection.[150] 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 (2000) who said Van Howe used an inappropriate method for combining studies, stating that re-analysis of the same data revealed that the presence of the foreskin was associated with increased risk of HIV infection (fixed effects OR 1.43, 95%CI 1.32 to 1.54; random effects OR 1.67, 1.25 to 2.24).[151] Moses et al. (1999) also criticised Van Howe's paper, stating that his results were a case of "Simpson's paradox, which is a type of confounding that can occur in epidemiological analyses when data from different strata with widely divergent exposure levels are combined, resulting in a combined measure of association that is not consistent with the results for each of the individual strata." They concluded that, contrary to Van Howe's assertion, the evidence that lack of circumcision increases the risk of HIV "appears compelling".[152]

Weiss, Quigley and Hayes carried a meta-analysis on circumcision and HIV in 2000[153] 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."

Siegried et al. (2003) surveyed 35 observational studies relating to HIV and circumcision: 16 conducted in the general population and 19 in high-risk populations.

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.[154]

In 2005, Siegfried et al. published a review in which 37 observational studies were included. Most studies indicated an association between lack of circumcision and increased risk of HIV, but the quality of evidence was judged insufficient to warrant implementation of circumcision as a public health measure. The authors stated that the results of the three randomised controlled trials then underway would therefore provide essential evidence about the effects of circumcision as an HIV intervention.[155]

The report on 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), stated that the rate of HIV infection was non-significantly lower among men who were circumcised compared with those who were uncircumcised.[156] For men who engaged primarily in insertive anal sex, a protective association was reported, 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 men who have sex with men against HIV infection.[156]

Three randomised control trials were commissioned to investigate whether circumcision could lower the rate of HIV contraction.

On Wednesday, March 28, 2007, the World Health Organisation (WHO) and UNAIDS issued joint recommendations concerning male circumcision and HIV/AIDS.[157] 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.[5]

Published meta-analyses, using data from the RCTs, have estimated the summary relative risk at 0.42 (95% CI 0.31-0.57),[158] 0.44 (0.33-0.60)[159] and 0.43 (0.32-0.59).[160] (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.[158] 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).[160] Weiss et al. report that the estimated relative risk using RCT data was "identical" to that found in observational studies (0.42).[158] 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."[160] 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.[159] Weiss et al. conclude that the evidence from the trials is conclusive, but that challenges to implementation remain, and will need to be faced.[158]

Other Sexually transmitted infections

A recent systematic review 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.[161]

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.[162][163] 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.[164]

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.”[15][165] 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.[166] Non-circumcised men are told not to wash with soap as it can inflame the penis.[167]

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 be a factor in causing balanitis.[168]

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.[169] 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.”[170]

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."[171]

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.[172]

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.[173]

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.[174]

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.[175][176][177] The reasons are unclear, but several hypotheses have been suggested:

Some mothers believe that circumcision will relieve them and the child of the bother of cleanliness, however Patel (1966) insists this is incorrect.[179]

Balanitis

Balanitis, an inflammation of the glans penis, has several causes.[180] Some of these, such as anaerobic infection, occur more frequently in uncircumcised men.[181] 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.[182] One study found more than five times the rate of balanitis in the uncircumcised men in the study group.[183] The most common complication of balanitis is phimosis, or inability to retract the foreskin from the glans penis.[184]

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."[184] O'Farrell et al. noted inferior hygiene among uncircumcised men attending a sexually transmitted infections (STI) clinic at Ealing Hospital, London.[185] 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.[186] 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.[167]

In a birth cohort of 500 boys studied from birth to 8 years of age, Fergusson et al. reported that the rate of penile inflammation problems per 100 boys at risk was 7.6 among circumcised boys and 14.4 among uncircumcised boys.[175] In a retrospective study of 545 boys, Herzog and Alverez found that balanitis occurred in 5.9% of the uncircumcised and 2.9% of the circumcised children; the difference was not statistically significant.[177] In a cross-sectional study of 398 patients, Fakjian et al. reported that balanitis was diagnosed in 12.5% of the uncircumcised men and 2.3% of the circumcised men.[176] In a study of 225 men, O'Farrell et al. found that circumcised men were less likely to be diagnosed with balanitis than uncircumcised men.[187] Van Howe found that circumcised penes required more care in the first 3 months of life. He found that circumcised boys were more likely to develop balanitis.[188]

Treatments that are less invasive than circumcision are effective in treating most mild cases of balanitis.[180] 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.”[167] The less invasive procedures are not as successful in treating balanitis xerotica obliterans, or BXO,[189][190][191] which is much less common but harder to treat.[192] 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.[193]

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 [194][195] 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%." They recommend circumcision as a last resort only in cases of recurrent balanitis.[196]

Images of balanitis[197][198][199]

Urinary tract infection (UTI)

Infections of the urinary tract (kidneys, ureters, bladder and urethra) can generally be treated effectively with antibiotics, though in rare cases they 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.[28]

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.[15]

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.[200]

The American Medical Association cites evidence that the incidence of UTIs 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)."[12]

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%.[201]

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.[202] Newman (2002) found that lack of circumcision was associated with a UTI.[203] Cason et al. (2000) investigated the effect of circumcision on recurrent UTI. Of 744 male infants admitted to the hospital's neonatal intensive care unit, 38 had UTI's. None of the premature infants in the study had a recurrent UTI once a circumcision was performed.[204] 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.[205]

Mueller et al. (1997) investigated the contribution of underlying genitourinary (GU) structural abnormalities to UTI. They 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.[206]

Glennon et al. examined periurethral carriage of Proteus mirabilis (a common cause of UTI in boys) in 60 circumcised and 124 uncircumcised boys. The researchers grew P mirabilis from swabs taken from 22.6% of the uncircumcised boys and 1.7% of the circumcised boys, concluding that their results support the idea that the prepuce may be the source of UTI infection.[207] Serour et al. swabbed the periurethral areas of 46 circumcised and 125 uncircumcised males, reporting that facultative Gram-negative rods were more common among uncircumcised males. The authors stated that their findings were "in accordance with a previous finding of increased risk of urinary tract infection in uncircumcised young men."[208] Wiswell et al. obtained intraurethral and circumferential glans cultures from a total of 300 boys, concluding that the foreskin was associated with a "greater quantity of periurethral bacteria and a greater likelihood for the presence of, as well as higher concentrations of, potentially uropathogenic organisms."[209] Wijesinha et al. conducted a prospective study of periurethral bacterial flora among 25 boys undergoing circumcision. Before circumcision, uropathogens were observed in 52% of boys. After circumcision, none were observed.[210] Gunsar et al. reported on a prospective study of 50 boys. The periurethral and glanular sulcus flora were evaluated before and after circumcision. Pathogenic bacteria were identified in periurethral swabs taken from 64% of patients before circumcision and 10% after. From the glanular sulcus area, pathogenic bacteria were identified in 68% of boys before circumcision, and 8% afterwards.[211] Fussell et al. reported that pathogenic bacteria adhere to the mucosal surface of the foreskin, commenting that this finding would appear to be related to the higher incidence of UTI in uncircumcised males.[212]

The Canadian Paediatric Society questions whether increased UTI and balanitis rates in uncircumcised male infants may be caused by forced premature retraction.[41] Cunningham also mentioned this in response to an early study by Wiswell, Smith and Bass.[213] 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.[214]

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.[215]

Skin conditions

Researchers from the Imperial College School of Medicine, Chelsea & Westminster Hospital, London, England reported the results of their study of 357 patients referred for genital skin disease:[216]

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".[217]

There are a few cases of skin diseases such as staphyloccal scalded skin syndrome or impetigo following circumcision.[218][219] 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.." .[220]

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,[221] also known as Balanitis Circumscripta Plasmacellularis or plasma cell balanitis (PCB) is an idiopathic, rare, benign penile dermatosis, usually of a middle-aged or older man.[222] Circumcision is the usual treatment of choice but fusidic acid cream 2% has been curative in some cases.[223][224]

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[45] 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.[225] According to these newer publications, 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 who confuse it with the developmentally non-retractable foreskin,[226] and Rickwood et al. write in their 2000 paper "Towards evidence based circumcision of English boys" in the British Medical Journal:[227]

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.[228]

It has been observed that Øster's study may not be representative of wider populations.[229] 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.[229] Reporting on a New Zealand study, Fergusson et al. found that 3.7% of boys had phimosis,[175] while Herzog and Alvarez found it in 2.6%.[177] Dawson and Whitfield say "True phimosis is rare but may cause appreciable problems in either childhood or adolescence."[230] The AAP state that the true frequency of problems such as phimosis is unknown.[15]

Several researchers have described less invasive treatments for phimosis than circumcision, and recommend that they be tried first.[231][232] Several studies have identified phimosis as a risk factor for penile cancer.

Phimosis is also a complication of circumcision, which can occur when too little foreskin is removed.[233]

Images of phimosis.[234][235][236]

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."[237]

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.[45]

Several techniques to treat paraphimosis are listed in an article in the American Family Physician,[237] and in the anti-circumcision web site CIRP.[238] One procedure is minor surgery to make a small slit in the foreskin without removing any tissue.[239] Another is called the "Dundee technique."[240] An article in the American Family Physician says that paraphimosis is one of the medical indications for circumcision.[241] The Royal Children's Hospital in Melbourne, Australia, says, "Once reduced, a single episode of paraphimosis is not an indication for circumcision."[242]

Images of paraphimosis: Figure 1 in Choe, 2000;[237] and Circlist.com[243]

See also

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.
  1. ^ a b Milos, M; MacRis, D (1992). "Circumcision A medical or a human rights issue?". Journal of Nurse-Midwifery 37 (2 Suppl): S87. doi:10.1016/0091-2182(92)90012-R. PMID 1573462. 
  2. ^ Krieger, John N.; Mehta, Supriya D.; Bailey, Robert C.; Agot, Kawango; Ndinya-Achola, Jeckoniah O.; Parker, Corette; Moses, Stephen (2008). "Adult Male Circumcision: Effects on Sexual Function and Sexual Satisfaction in Kisumu, Kenya". Journal of Sexual Medicine 5 (11): 2610–22. doi:10.1111/j.1743-6109.2008.00979.x. PMC 3042320. PMID 18761593. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=3042320. 
  3. ^ Schoen (2007). "Should newborns be circumcised? Yes". Canadian Family Physician 53 (12): 2096–8, 2100–2. PMC 2231533. PMID 18077736. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=2231533. 
  4. ^ a b "Non-therapeutic circumcision of male minors (2010)". KNMG. 12 June 2010. http://knmg.artsennet.nl/Diensten/knmgpublicaties/KNMGpublicatie/Nontherapeutic-circumcision-of-male-minors-2010.htm. 
  5. ^ a b (PDF) New Data on Male Circumcision and HIV Prevention: Policy and Programme Implications. World Health Organization. March 28, 2007. http://www.who.int/hiv/mediacentre/MCrecommendations_en.pdf. Retrieved 2007-08-13. 
  6. ^ "Male Circumcision and Risk for HIV Transmission and Other Health Conditions: Implications for the United States". Centers for Disease Control and Prevention. 2008. http://www.cdc.gov/hiv/resources/factsheets/circumcision.htm. 
  7. ^ "Current College Position on Circumcision". Royal Australasian College of Physicians. 2009-08-27. http://racp.edu.au/download.cfm?DownloadFile=59AE2C7C-9F08-B344-21061157DF3636B9. 
  8. ^ "Circumcision: Information for parents". Caring for kids. Canadian Paediatric Society. November 2004. Archived from the original on 2005-12-19. http://web.archive.org/web/20051219215229/http://www.caringforkids.cps.ca/babies/Circumcision.htm. Retrieved 2006-10-24. "Circumcision is a “non-therapeutic” procedure, which means it is not medically necessary. Parents who decide to circumcise their newborns often do so for religious, social or cultural reasons. To help make the decision about circumcision, parents should have information about risks and benefits. It is helpful to speak with your baby’s doctor. After reviewing the scientific evidence for and against circumcision, the CPS does not recommend routine circumcision for newborn boys. Many paediatricians no longer perform circumcisions." 
  9. ^ Fetus and Newborn Committee (March 1996). "Neonatal circumcision revisited". Canadian Medical Association Journal 154 (6): 769–780. PMC 1487803. PMID 8634956. http://www.cps.ca/english/statements/FN/fn96-01.htm. Retrieved 2006-07-02.  “We undertook this literature review to consider whether the CPS should change its position on routine neonatal circumcision from that stated in 1982. The review led us to conclude the following. There is evidence that circumcision results in an approximately 12-fold reduction in the incidence of UTI during infancy. The overall incidence of UTI in male infants appears to be 1% to 2%. The incidence rate of the complications of circumcision reported in published articles varies, but it is generally in the order of 0.2% to 2%. Most complications are minor, but occasionally serious complications occur. There is a need for good epidemiological data on the incidence of the surgical complications of circumcision, of the later complications of circumcision and of problems associated with lack of circumcision. Evaluation of alternative methods of preventing UTI in infancy is required. More information on the effect of simple hygienic interventions is needed. Information is required on the incidence of circumcision that is truly needed in later childhood. There is evidence that circumcision results in a reduction in the incidence of penile cancer and of HIV transmission. However, there is inadequate information to recommend circumcision as a public health measure to prevent these diseases. When circumcision is performed, appropriate attention needs to be paid to pain relief. The overall evidence of the benefits and harms of circumcision is so evenly balanced that it does not support recommending circumcision as a routine procedure for newborns. There is therefore no indication that the position taken by the CPS in 1982 should be changed. When parents are making a decision about circumcision, they should be advised of the present state of medical knowledge about its benefits and harms. Their decision may ultimately be based on personal, religious or cultural factors.
  10. ^ a b Medical Ethics Committee (June 2006). "The law and ethics of male circumcision - guidance for doctors". British Medical Association. http://www.bma.org.uk/ethics/consent_and_capacity/malecircumcision2006.jsp. Retrieved 2009-07-23. "Circumcision for medical purposes
    Unnecessarily invasive procedures should not be used where alternative, less invasive techniques, are equally efficient and available. It is important that doctors keep up to date and ensure that any decisions to undertake an invasive procedure are based on the best available evidence. Therefore, to circumcise for therapeutic reasons where medical research has shown other techniques to be at least as effective and less invasive would be unethical and inappropriate. Male circumcision in cases where there is a clear clinical need is not normally controversial. Nevertheless, normal anatomical and physiological characteristics of the infant foreskin have in the past been misinterpreted as being abnormal. The British Association of Paediatric Surgeons advises that there is rarely a clinical indication for circumcision. Doctors should be aware of this and reassure parents accordingly.

    Non-therapeutic circumcision
    Male circumcision that is performed for any reason other than physical clinical need is termed non-therapeutic (or sometimes “ritual”) circumcision. Some people ask for non-therapeutic circumcision for religious reasons, some to incorporate a child into a community, and some want their sons to be like their fathers. Circumcision is a defining feature of some faiths.

    There is a spectrum of views within the BMA’s membership about whether non-therapeutic male circumcision is a beneficial, neutral or harmful procedure or whether it is superfluous, and whether it should ever be done on a child who is not capable of deciding for himself. The medical harms or benefits have not been unequivocally proven except to the extent that there are clear risks of harm if the procedure is done inexpertly. The Association has no policy on these issues. Indeed, it would be difficult to formulate a policy in the absence of unambiguously clear and consistent medical data on the implications of the intervention. As a general rule, however, the BMA 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."
     
  11. ^ "Circumcision policy statement. American Academy of Pediatrics. Task Force on Circumcision". Pediatrics 103 (3): 686–93. 1999. doi:10.1542/peds.103.3.686. PMID 10049981. "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. 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. It is legitimate for parents to take into account cultural, religious, and ethnic traditions, in addition to the medical factors, when making this decision. Analgesia is safe and effective in reducing the procedural pain associated with circumcision; therefore, if a decision for circumcision is made, procedural analgesia should be provided. If circumcision is performed in the newborn period, it should only be done on infants who are stable and healthy." 
  12. ^ a b c d e f "Report 10 of the Council on Scientific Affairs (I-99):Neonatal Circumcision". 1999 AMA Interim Meeting: Summaries and Recommendations of Council on Scientific Affairs Reports. American Medical Association. December 1999. pp. 17. http://www.ama-assn.org/ama/pub/category/13585.html. Retrieved 2006-06-13. 
  13. ^ "Circumcision: Position Paper on Neonatal Circumcision". American Academy of Family Physicians. 2007. http://www.aafp.org/online/en/home/clinical/clinicalrecs/circumcision.html. Retrieved 2007-01-30. "Considerable controversy surrounds neonatal circumcision. Putative indications for neonatal circumcision have included preventing UTIs and their sequelae, preventing the contraction of STDs including HIV, and preventing penile cancer as well as other reasons for adult circumcision. Circumcision is not without risks. Bleeding, infection, and failure to remove enough foreskin occur in less than 1% of circumcisions. Evidence-based complications from circumcision include pain, bruising, and meatitis. More serious complications have also occurred. Although numerous studies have been conducted to evaluate these postulates, only a few used the quality of methodology necessary to consider the results as high level evidence.

    The evidence indicates that neonatal circumcision prevents UTIs in the first year of life with an absolute risk reduction of about 1% and prevents the development of penile cancer with an absolute risk reduction of less than 0.2%. The evidence suggests that circumcision reduces the rate of acquiring an STD, but careful sexual practices and hygiene may be as effective. Circumcision appears to decrease the transmission of HIV in underdeveloped areas where the virus is highly prevalent. No study has systematically evaluated the utility of routine neonatal circumcision for preventing all medically-indicated circumcisions in later life. Evidence regarding the association between cervical cancer and a woman’s partner being circumcised or uncircumcised, and evidence regarding the effect of circumcision on sexual functioning is inconclusive. If the decision is made to circumcise, anesthesia should be used.

    The American Academy of Family Physicians recommends physicians discuss the potential harms and benefits of circumcision with all parents or legal guardians considering this procedure for their newborn son."
     [dead link]
  14. ^ American Urological Association. "Circumcision". About AUA - Policy Statements. http://www.auanet.org/content/guidelines-and-quality-care/policy-statements/c/circumcision.cfm. Retrieved 2007-08-26. 
  15. ^ a b c d e f g "Circumcision policy statement. American Academy of Pediatrics. Task Force on Circumcision". Pediatrics 103 (3): 686–93. 1999. doi:10.1542/peds.103.3.686. PMID 10049981. 
  16. ^ Schoen EJ, Wiswell TE, Moses S (March 2000). "New policy on circumcision--cause for concern". Pediatrics 105 (3 Pt 1): 620–3. doi:10.1542/peds.105.3.620. PMID 10699119. 
  17. ^ Lannon CM, Bailey A, Fleischman A, Shoemaker C, Swanson J (March 2000). "Circumcision debate. Task Force on Circumcision, 1999-2000". Pediatrics 105 (3 Pt 1): 641–2. doi:10.1542/peds.105.3.641. PMID 10699124. 
  18. ^ Schoen, E. J.; Wiswell, T. E.; Moses, S. (2001). "Reply to Carole M. Lannon and the Task Force on Circumcision". Pediatrics 108 (1): 211. doi:10.1542/peds.108.1.211. PMID 11452959. 
  19. ^ "Circumcision (Infant Male)". Resource manual. College of Physicians and Surgeons of British Columbia. 2004. https://www.cpsbc.ca/files/u6/Circumcision-Infant-Male.pdf. Retrieved 2009-08-16. 
  20. ^ Cadman, D.; Gafni, A; McNamee, J (1984). "Newborn circumcision: an economic perspective". Canadian Medical Association Journal 131 (11): 1353–5. PMC 1483656. PMID 6437656. http://www.cmaj.ca/cgi/content/abstract/131/11/1353. 
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  130. ^ Ronald L. Poland (1990). "The question of routine neonatal circumcision". The New England Journal of Medicine 22 (18): 1312–1315. doi:10.1056/NEJM199005033221811. http://www.cirp.org/library/general/poland/. 
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  148. ^ "Policy Statement On Circumcision" (PDF). Royal Australasian College of Physicians. September 2004. http://www.racp.edu.au/download.cfm?DownloadFile=A453CFA1-2A57-5487-DF36DF59A1BAF527. Retrieved 2007-02-28. "The Paediatrics and Child Health Division, The Royal Australasian College of Physicians (RACP) has prepared this statement on routine circumcision of infants and boys to assist parents who are considering having this procedure undertaken on their male children and for doctors who are asked to advise on or undertake it. After extensive review of the literature the RACP reaffirms that there is no medical indication for routine neonatal circumcision. Circumcision of males has been undertaken for religious and cultural reasons for many thousands of years. It remains an important ritual in some religious and cultural groups.…In recent years there has been evidence of possible health benefits from routine male circumcision. The most important conditions where some benefit may result from circumcision are urinary tract infections, HIV and later cancer of the penis.…The complication rate of neonatal circumcision is reported to be around 1% to 5% and includes local infection, bleeding and damage to the penis. Serious complications such as bleeding, septicaemia and meningitis may occasionally cause death. The possibility that routine circumcision may contravene human rights has been raised because circumcision is performed on a minor and is without proven medical benefit. Whether these legal concerns are valid will be known only if the matter is determined in a court of law. 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. In all cases where parents request a circumcision for their child the medical attendant is obliged to provide accurate information on the risks and benefits of the procedure. Up-to-date, unbiased written material summarising the evidence should be widely available to parents. Review of the literature in relation to risks and benefits shows there is no evidence of benefit outweighing harm for circumcision as a routine procedure in the neonate." [dead link]
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  151. ^ O'Farrell N, Egger M (2000). "Circumcision in men and the prevention of HIV infection: a 'meta-analysis' revisited". Int J STD AIDS 11 (3): 137–42. doi:10.1258/0956462001915480. PMID 10726934. "The results from this re-analysis thus support the contention that male circumcision may offer protection against HIV infection, particularly in high-risk groups where genital ulcers and other STDs 'drive' the HIV epidemic. A systematic review is required to clarify this issue. Such a review should be based on an extensive search for relevant studies, published and unpublished, and should include a careful assessment of the design and methodological quality of studies. Much emphasis should be given to the exploration of possible sources of heterogeneity. In view of the continued high prevalence and incidence of HIV in many countries in sub-Saharan Africa, the question of whether circumcision could contribute to prevent infections is of great importance, and a sound systematic review of the available evidence should be performed without delay." 
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  165. ^ Although the Academy's 1975 statement asserted that "A program of education leading to continuing good personal hygiene would offer all the advantages of circumcision without the attendant surgical risk," the 1999 statement cites a study which found that "appropriate hygiene decreased significantly the incidence of phimosis, adhesions, and inflammation, but did not eliminate all problems."
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  176. ^ a b Fakjian, N; S Hunter, GW Cole and J Miller (August 1990). "An argument for circumcision. Prevention of balanitis in the adult". Arch Dermatol 126 (8): 1046–7. doi:10.1001/archderm.126.8.1046. PMID 2383029. 
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  178. ^ O’Farrel, Nigel; Maria Quigley and Paul Fox (August 2005). "Association between the intact foreskin and inferior standards of male genital hygiene behaviour: a cross-sectional study". International Journal of STD & AIDS 16 (8): 556–588(4). doi:10.1258/0956462054679151. PMID 16105191.  Editor’s note: I cannot confirm that the article substantiates the claim as I cannot access the full article.
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